Care Coordination System for Chronic Disease Management
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Solution Overview
Problem
The healthcare system faces inefficiencies and high costs due to a lack of community or ambulatory care coordination for patients with chronic diseases, leading to fragmented care and frequent hospital readmissions.
Innovation Solution
A care coordination system that selects patients for coordination based on diagnosis and data analytics, assigns and customizes patient care flow plans, engages patients through scheduling, notifications, and home monitoring, and transitions care between healthcare providers, using a computer-readable medium and software as a service (SaaS) environment.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Reliability
If a fragmented and reactive clinical model is used for post-discharge care, then healthcare providers can operate with limited resources and time constraints, but patients experience disconnection from community care and frequent hospital readmissions
Solution Approach 1:
The system segments the care coordination process into distinct functional modules including patient identification module, care plan generation module, provider coordination module, and monitoring module. Each module handles specific tasks independently, allowing the complex care coordination function to be broken down into manageable components that can be implemented and maintained with existing resources
Solution Approach 2:
The system acts as an intermediary platform that connects patients, primary care providers, specialists, and hospital systems. This mediator coordinates care transitions and information exchange between different healthcare entities, enabling continuous care monitoring without requiring direct complex interactions between all parties
2Productivity
If traditional healthcare delivery models are used without care coordination, then operational simplicity is maintained, but healthcare costs increase due to frequent readmissions and ER utilization
Solution Approach 1:
The system performs preliminary actions by identifying high-risk patients before discharge and establishing care coordination plans in advance. The patient identification module uses criteria-based screening to flag patients who need coordinated care, and care plans are prepared before the patient leaves the hospital, enabling proactive rather than reactive care management
Solution Approach 2:
The system implements continuous feedback loops where patient data, care plan adherence, and health status information are monitored and fed back to providers and the coordination system. This feedback mechanism enables real-time adjustments to care plans and early intervention when patients show signs of deterioration, preventing unnecessary readmissions
Data Source
AI summary
A system and method configured for coordinating healthcare services is disclosed. The method can comprise selecting a patient for care coordination based in part on a patient diagnosis and data analytics, assigning a predetermined patient care flow plan to a patient based in part on the patient diagnosis, modifying the predetermined patient care flow plan in response to input from at least one of a healthcare provider and the patient, and generating a customized patient care flow plan for the patient, executing the customized care flow, and engaging the patient by providing to the patient at least one of patient scheduling, notifications, a personal health record, patient home monitoring, and patient education and medication information materials. The present disclosure further includes computer program product of a computer-readable medium usable with a programmable computer and having computer-readable code embodied therein for coordinating healthcare services.