Long-Term Care

Assess care summaries received from primary care providers and hospitalists to inform and evaluate care plans prior to admission

Review previous hospital admissions, ED reports, allergy lists, office visit notes, laboratory work and radiology reports, immunizations, active problems, and chronic conditions from various sources

Enhance patient confidence and satisfaction by engendering greater collaboration with referring providers

Confirm correct medication lists during transitions of care by reviewing filled/dispensed medications (over last 120 days)

Prevent duplication of medications after discharge to avoid overprescribing, eliminating redundancies and extra costs

Monitor medications to prevent misuse and risk of harm

Identify potentially adverse drug combinations/interactions and/or dosing levels

Increase collaboration among primary care, specialty care, subspecialty care, and other care locations to improve the quality and safety of patients’ care interactions and experiences

Manage patients’ care transitions, care coordination agreements, and other protocols to support how care teams work together

Update care plans based upon a comprehensive review of supporting documentation and materials compiled from multiple providers from unaffiliated locations

Provide 24x7x365 secure access to patients’ electronic health records in support of care teams’ abilities to engage patients when it matters most

Allow care teams to identify and assign active patients to a panel to track and monitor their time-sensitive healthcare activities in real-time over the course of their treating relationship

Ensure acute-care discharge care plans are assembled with the following key components: review of medications, identification of necessary follow-up services, and description of relevant equipment needs

Ensure that duplicate laboratory tests and/or radiology reports are not ordered by reviewing patients’ comprehensive electronic health records

Advocate for patients when additional care is needed from another provider or specialist

Look for gaps in care to ensure activities are aligned across various healthcare settings

Reduce the need for unnecessary documentation for reimbursement purposes

Supports various performance reporting initiatives (e.g., ACO, CMS, MIPS, NCQA, etc.) by providing access to a centralized and comprehensive clinical data repository to fill in data gaps and longitudinal information

Assists with the completion of Minimum Data Set (MDS) sheets, including active diagnoses, pain assessments, fall histories, medications, immunizations, and procedures information

Tracks health outcomes and equity based on both clinical and community activities and determinants of health and wellbeing