Care Coordination Module
Comprehensive care coordination platform supporting case management, chronic disease management, care transitions, and interdisciplinary team collaboration.
Organization Relevance
How It Works
Care coordination identifies high-risk members through risk stratification and clinical alerts. Care managers open cases, develop care plans, and coordinate across providers. The chronic disease management module tracks condition-specific protocols. Care transitions ensure safe handoffs between settings. Clinical guidelines provide evidence-based decision support.
Requirements
- Risk stratification algorithm integration
- Care plan template library
- ADT notification feed from hospitals
- Clinical guideline repository
- Secure messaging for care team collaboration
Target Audience
Care Managers, Nurse Coordinators, Social Workers, Medical Directors, Care Teams
Pages (9)
| Page | Purpose | Key Features |
|---|---|---|
| Care Coordination Dashboard | Overview of active cases, risk levels, and care management metrics | Case metrics, Risk distribution, Team workload, Outcome tracking |
| Case Management | Create and manage care coordination cases with goals and interventions | Case creation, Goal tracking, Intervention management, Progress notes |
| Chronic Disease Management | Protocol-driven chronic condition management and monitoring | Condition protocols, Metric tracking, Patient education, Provider coordination |
| Clinical Alerts | Real-time clinical alerts for high-risk events and care gaps | Alert generation, Priority routing, Response tracking, Alert analytics |
| Clinical Guidelines | Evidence-based clinical guideline library for care decision support | Guideline library, Search and filter, Version management, Provider access |
| PACE Care | Program of All-Inclusive Care for the Elderly care management | PACE enrollment, IDT meetings, Service planning, Outcome tracking |
| Risk Scores | Member risk stratification scores and risk factor analysis | Risk scoring, Factor analysis, Trend tracking, Cohort comparison |
| Care Team | Interdisciplinary care team assignment and collaboration tools | Team assignment, Role management, Communication log, Workload balancing |
| Care Transitions | Manage care transitions between settings with handoff protocols | Transition tracking, Handoff checklists, Follow-up scheduling, Readmission prevention |
API Integrations
ADT notification API (HL7/FHIR)Care plan FHIR APIRisk score calculation APIClinical guideline APISecure messaging API
Referenced Resources
NCQA Population Health StandardsCMS Chronic Care Management GuidelinesDa Vinci Notifications IG (FHIR)AHRQ Care Coordination Measures
Expected Results
Improved health outcomes through proactive care management, reduced hospitalizations, better chronic disease control, and seamless care transitions.