An essential part of any outcome oriented model is the coordination of care across providers – requiring improved communication and information sharing within the whole community. ICW Care Coordination puts its focus on the core competencies required to address this challenge: Provide continuity-of-care information at the point of care, optimize transitions of care, plan and manage hospital discharges to reduce readmissions and avoid network leakage caused by out-of-network referrals.
Continuity-of-care information that is shared in a timely manner among the virtual care team greatly enhances provider collaboration. ICW Care Coordination integrates data and workflows across disparate applications and care settings. It creates a unified and up-to-date view of the patient at the point of care and provides insights that help to make the right decisions.
Discharge Management optimizes planning and coordination of care transitions and reduces preventable readmissions. High risk patients are identified upon hospital admission using data from the patients’ comprehensive health record. Post-discharge appointments are planned during hospital stay and facilitate the transition from hospital to ambulatory care.
By connecting clinicians with the information they need—when, where and how they need it—Referral Management transforms the onerous, bureaucratic, paper-shuffling referral process into a disciplined and effective workflow. With up-to-date provider network information referral leakage is reduced and end-to-end process transparency ensures that no referral gets lost.
ICWs integration of Care Coordination with ICW HIE also supports to streamline the management of patient flows, keep patients within the network and get insights into referral patterns and trends.Highlights
- Data and workflow integration across disparate applications and care settings
- A unified view of the patient across organizations and care settings
- Improved referral workflow efficiency with an automated process that eliminates paperwork, redundant data entry and unnecessary phone calls
- Post-discharge appointment planning with PCP, specialists, home care and other providers during hospital stay
- Increase overall healthcare quality and efficiency with continuity-of-care information that is shared in a timely manner among the virtual care team
- Improve Care Transitions – Manage referrals, share information with specialists and ensure that follow-up activities are completed
- Reduce patient leakage by making it easy for providers to find in-network specialists
- Reduce expenditures caused by preventable readmissions through efficient Discharge Management
- Enable PCMH by involving home stay patients to track progress on activities related to discharge tasks