The Context Of Care Coordination & Population Health Management Model

2. Aim Of Population Health Management Platform Population Health Management (PHM) aims to improve the healthcare quality of a group of individuals by monitoring and identifying specific patients within that group. The Population Health Management Platform provides real-time insights and coordinated interventions to care providers by identifying and addressing care gaps in the patient population. The well-designed Population Health Management Solutions improves healthcare outcomes and cost reductions by providing solutions to identify and manage the quality of care. The PHM Solutions facilitate care coordination by supporting interoperability across care services to connect chronically ill patients and their families with preventive care, effective services, and resources.

3. Care Coordination Process Care Coordination is a core component of the PHM platform that helps in the management of chronic conditions. It enables organizations to manage Pop Health effectively by developing connections between laboratory data, electronic health records, patient registries, and prescription data. Care Coordination is an information-rich process that optimizes patient-centered sustainable care through big data, decision-making, assessment, planning, interventions, and evaluation. These procedures are carried out at the population and individual levels.

4. Big Data & Decision-Making The data analysis determines the population’s specific requirements and problems particularly those at risk of fatality and complications. The data analysis also identifies the variables involved in problem-solving and decision-making for quality care. Assessment Assessment is an essential feature of Care Coordination as it ensures that crucial information is available for the planning and intervention stages. A thorough assessment identifies the high-risk individuals’ specific problems and needs that must be addressed and prioritized.

5. Planning After gathering information about identified problems and needs of the target group, the planning phase helps address the issues. The first phase is to develop a plan to improve the health of the target group. There is a possibility that the target group may require more than one plan, depending on the intricacy of the problem or need.

6. Interventions The interventions should address the target group's needs adequately. The interventions fall into three distinct and interconnected categories: • Preventive Measures: The preventive measures focus on preventative care, early detection of disease, and injury prevention. • Care Transitions: Care Coordination during care transitions can identify the underlying factors of problems such as communication gaps related to sharing of clinical records and timely follow-ups with the caregiver. • Care for Chronic Diseases Clinical decision support systems are a critical element for providers who care for chronically sick patients.

7. Evaluation The final stage of care coordination is an evaluation to improve care outcomes. Re-evaluate the care plan regularly and identify the new needs. Keep the healthcare report up-to-date by re-evaluating the data and insights from different sources. Care Coordination for Payers Healthcare Payers have an influence on care coordination; hence it is critical to have a system that allows easy transactions, data audits, reimbursements, approvals, and referrals connected to the healthcare system.

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