Care management is another key element of JCMC’s valued-based care success. The multi-faceted program includes two dedicated care managers who focus on follow-up calls related to: all emergency room and hospital encounters, all “no show” office visits as part of preventive care, and all after-hours help line calls to assess the need for evaluation and an appointment with the primary care physician (PCP). In addition, the care managers identify community resources, with the goal of reducing or eliminating barriers to care. The care management program also coordinates with the care team to offer medication reconciliation to further identify patient needs and schedule follow-up PCP visits.
Another aspect of care management is care coordination, which is especially critical when patients need specialist referrals. JCMC leverages Infina Connect’s Intelligent Care Coordinator™ to give its PCPs the ability to direct patients to specialists within high value, virtual delivery networks when appropriate. This technology enables the exchange of clinical documents bi-directionally between disparate EHRs, ensuring collaborative care throughout the patient journey. By reducing referral leakage, JCMC further optimizes value-based reimbursement while delivering better care at a lower cost.
JCMC also utilizes Smartlink Health Solutions with SPH Analytics integration to take multiple, disparate data sources from EHRs, claims data and more, and bring it into the SPH Analytics engine to do risk stratification and identify care gaps, which are vital to population health management. Those care gaps are then pushed back into the EHR and care management system, empowering the physician and care managers with the right information at the right time within the clinical workflow.
Lastly, JCMC supplies its physicians with access to Smartlink Data Connector™, which automates the process of checking state prescription drug monitoring program (PDMP) databases, granting an informed prescribing decision while reducing administrative burdens. Checking the PDMP before prescribing opioids or controlled substances is required by North Carolina state law and is acknowledged as one of the most promising tools in identifying and preventing potential opioid abuse. The Smartlink solution automates the otherwise burdensome process of checking the state PDMP, making it easy for providers to comply with the law.
With its technology-driven care management system, complemented by the high-touch of its care managers, JCMC has improved clinical outcomes such as its enviable preventable hospital readmissions rate that is 75 percent below the regional average.