Episode Connect, our proprietary suite of software applications, is a powerful care coordination tool delivered via web and mobile apps. It's the 'connective tissue' between program managers, nurses, physicians, patients and family that makes a bundled payment program successful.
Table of Contents:
Clinical Data Aggregation
Patient Onboarding & Assessment
Customizable Care Plans
Site of Care Selection
Principal Accountable Practitioner (PAP) Assignment
Quality Measures: Collection & Reporting
Physician Connect for Physicians/Clinicians
Patient Connect for Patients and Their Families
Workflow Tools for Nurses & Call Centers
CLINICAL DATA AGGREGATION
Partner specific data, reports, and performance measurement
- Partner integration allows us to receive HL7 feeds from electronic health records
- Compilation and tracking of physician orders, medication changes and care plans over an episode of care
- Maintenance of database for reports and performance measurement
PATIENT ONBOARDING & ASSESSMENT
Patient ID and risk stratification to reduce preventable readmissions
Eligibility - Patient Identification
Early identification of bundled payment patients by integrating with each hospital's Admission/Discharge/Transfer (ADT) data and the Clinical Document Improvement (CDI) processes.
Includes assessment tools informing readmission risk, next site of care and post-acute facility length of stay targets
Patient Stratification Algorithms
Assignment of patients to risk levels to drive post-acute interventions with scheduled follow-up services.
CUSTOMIZABLE CARE PLANS
90 day care plans customized for each patient
- Patient-specific goals, tasks and interventions
- "Calendaring" of care plans, allow a patient’s care team to pre-schedule their interventions
- Users can rely on existing library of care plans, which include ‘modifiers’ for complications and co-morbidities, or users can use the platform to create their own customized plans.
SITE OF CARE SELECTION
Ensuring the patient's next site of care is appropriate for their needs
- An assessment of patient suitability for home or SNF care
- Detailed output regarding a patient’s specific ‘Skilled’ needs and needs for other support and custodial services.
- Patient/SNF matching
- A communications module assuring SNF, HHA or family receives complete instructions and expectations
PRINCIPAL ACCOUNTABLE PRACTITIONER (PAP) ASSIGNMENT
Physicians involved in patient’s care plan through the entirety of an episode
Remedy designates a gainsharing physician as the Principal Accountable Practitioner (PAP) to participate in patient care coordination activities for each stage of a patient's episode.
In most cases, multiple PAPs will manage a patient’s care. Episode Connect manages any hand-offs or information flow between these physicians. This module also enables nurses and Program Managers to affirm designation for a particular stage, leading to a cascade of communication events aiding in physicians’ participation.
HIPPA compliant communication between patient and their care team
- HIPAA compliant messaging with all care team members and patients
- Empowers family and caregiver to connect directly to Care Teams and health care providers, enabling important sending/receiving of alerts and updates.
QUALITY MEASURES: COLLECTION & REPORTING
Encouraging high standards of quality and accountability
- Processes to collect quality metrics during the episode of care
- Patient self-reporting of outcomes through Patient Connect
- Reporting on quality outcomes required by CMS and payer contracts
PHYSICIAN CONNECT FOR PHYSICIANS/CLINICIANS
Web and mobile apps to facilitate the clinical management of patient care
- Web and mobile app enabling physicians and hospitals to easily on-board and track patients
- Patient lists, including retrieval of information from hospital medical records, SNF and HHA data feeds, patient assessments, and family/caregiver feedback
- Entry of alerts, medication changes and other instructions for the patient's care team
- HIPAA-compliant communication with the patient, their family and their care team
PATIENT CONNECT FOR PATIENTS AND THEIR FAMILIES
Web and mobile app that keep the Patient/Family informed about their care
- Access to medical records collected during the episode of care from hospital, SNF, HHA and physician EMRs.
- Contact information for physicians, post acute providers, case managers and care givers.
- Curated Patient education materials unique to each disease and condition
- A library of patient surveys and feedback questions enhancing patient and caregiver engagement in plan of care
- Program Managers can use administrative portals to add new surveys and patient teach-back quizzes
- Medication management tools (coming)
- Care plan tracking
- Daily collection of patient-specific activities
- Communication tools to connect with physicians, nurses and other care team members
- Care Team Creation
- The ability to invite family and friends into the HIPAA compliant Episode Connect portals to help patients manage their care and provide updates on patient condition
WORKFLOW TOOLS FOR NURSES & CALL CENTERS
Systems to organize and track all patient episodes of care
- Remedy has created software for managing large numbers of patients in episode of care bundles. Some features include:
- Assignment of nurses to patients
- On-boarding module
- Care plan templates for creating novel care plans
- Assignment of care plans to patients; population of calendar with tasks and interventions
- Communications module
- Notes and updates on patient progress