1 / 23

Optimizing Care Transitions with RIQI Tools

Learn how to optimize care transitions and improve care coordination using RIQI tools such as alerts, dashboards, and CurrentCare. Discover the benefits of CurrentCare for PCPs, designee alerts, and resources tailored to your practice and patient panel.

tuyetd
Download Presentation

Optimizing Care Transitions with RIQI Tools

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Optimizing Care Transitions with RIQI Tools • Using Care Management Tools • Alerts • Dashboard • New Dashboard features (identifying high risk) • Using CurrentCare: fill gaps and find the data you need • CurrentCare Hospital Alerts for PCPs • Optimize CurrentCare Enrollment • CurrentCare for Me • Designee Alerts • Resources for you practice

  2. Based on your patient panel • Near real time data for hospital (ED and Inpatient) admissions and discharges • Encounter data and risk scores (*new) Care Management Services • Rhode Island’s Health Information Exchange • Opt-in: patients need to enroll • Data repository: medications, lab results, discharge documents and more

  3. Care Management Tools: • Alerts • Dashboards

  4. Care Management Services Patient visits ED, Hospital, SNF Real-time CM Alerts Received by Care Team Alerts ADT Practices, ACOs RIQI Care Management Services Real-time CM Dashboards Available to Care Team Dashboards

  5. Care Management Alerts Lifespan Discharges include CoC Document Near real time updates from RI acute care hospitals Screenshots contained in this document and on any training files do not contain Protected Health Information (PHI). All data presented for training purposes has been randomly generated from databases of fictitious data.

  6. Care Management Dashboard Admitted Discharged ….. Data is updated every 10 minutes Trending

  7. Navigating - View Details • Each encounter is displayed as a row in the patient lists

  8. Navigating - View Details • Use the Care Management Dashboard to find key data for Care Transitions: • Reason for Admission • Discharge Location (when available) • Discharge Disposition (code with reference source)

  9. Navigating – View all encounters • View list of all this patient’s encounters (Inpatient, ED, Outpatient) *New Dashboard feature

  10. NEW: Risk Scores • CharlsonComorbidity Index– Predictor of mortality risk based on a weighted score of chronic conditions. • LACE index– Indicator of readmission risk based on: • Length of stay / Acuity of admission / Charlson Comorbidity Index / ED – 6 mos ED visit count.

  11. Care Management Tools: Improving Care Transitions and Care Coordination CareLink Community Health Team: Case Managers in the Emergency Departments are often overwhelmed because they have so many activities they need to set-up for patients. It makes it easier for them when we are able to coordinate care and they know they can rely on us to get the services a patient needs beyond the hospital setting. Rhode Island Primary Care Physicians Corp. (RIPCPC) Nurse Care Managers: By having timely and reliable admission and discharge information for all our patients, we can be sure to effectively target the needs of each individual in our care. We can ensure they have follow-up appointments scheduled with the right doctors. We can also make sure that they have other specific support and care, depending on the situation.

  12. CurrentCare: • Viewer/ CurrentCare in EHRs • Hospital Alerts for PCPs

  13. CurrentCare: Rhode Island’s HIE Medical Professionals can see patient data via the CurrentCare Viewer Health Information Exchange Consumers can view and download their record via CurrentCare for Me

  14. Need More Information? Care Management Dashboard • In CurrentCare: • Lifespan CoC • Discharge Summaries (Fatima & Roger Williams) • Medical Record Summaries • Medications, Lab Results, Imaging and More

  15. CurrentCare: Building a Resource • Medication data, lab results, imaging reports, allergies, problems/diagnoses • Discharge documents: • Lifespan Continuity of Care Document • Fatima and Roger Williams discharge summaries • Clinical summaries (CCDs) also helpful for care transitions • *Coming Soon: Landmark discharge CoC, SCH discharge summary, information from Yale New Haven Health and more SNF data

  16. CurrentCare Enrollment • RI is an “Opt-In” state • More than 500,000 Rhode Islanders have enrolled

  17. CurrentCare and VLER: for RI Veterans

  18. CurrentCare Hospital Alerts Must be enrolled in CurrentCare CurrentCare enrollee visits hospital Hospital Alert received by care team Health information of enrolled patients Must Identify PCP PCP must subscribe to Alerts

  19. About Hospital Alerts Lifespan Discharges include CoC Document

  20. Support Enrollment: CurrentCare Informational Video https://enroll.currentcareri.org/

  21. Thank you! • Questions?

More Related