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Client Profile

Our client was seeking to implement a patient-centered medical homes program for the Medicaid Provider network it was developing. States are adopting Medical Homes for their Medicaid populations to increase access primary providers who will manage their overall care. These populations currently have disjointed, if any, care coordination among their providers. Since the Medical Home concept is just now gaining ground in the US, there are no off the shelf software packages. The client had no infrastructure in place when they came to Deerwalk and had a potential population of 12,000 Medicaid members in year 1 of operations. The final product selected by the client would have to be approved by the state Medicaid Agency.

The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth and adults to promote continuity of care and to ensure optimal health management. The objective of a Medical Home network is to increase care coordination, reduce costs, and increase quality to ultimate benefit of the membership. A "Patient Centered program", means that the medical home would ensure its Primary Care Providers oversee the care of their assigned "population" of patients through the continuum of care. The medical home would call new members, encouraging them to get established with their PCP and use claims data to report quantitative indicators of quality.

Our client’s care coordination process includes:

• Working in partnership with their PCPs to coordinate care for their enrolled “population" of beneficiaries.
• Outreach to all new recipients, encouraging them to establish working relationship with their PCP.
• If necessary, assisting the members in finding a more suitable physician in order to create a collaborative relationship with the provider.
• Reviewing medical and pharmacy claim information to identify members who may require case and disease management.

Recipients who were identified through claims analysis requiring clinical intervention would be contacted and monitored. These members include those with diseases for which care plans would be helpful (e.g., diabetes, asthma, heart disease or complex cases) and those with disjointed care frequently using the ER as their primary care physician. For those less ill but needing education, the medical home would reach out. Follow up care of those discharged from the acute care setting to reduce the risk of re-admission is a primary objective. The goal is to prevent avoidable costs by having the member understand their medical condition and actively work to manage it.

Business Situation
The client needs to provide a medical home for Medicaid beneficiaries to promote continuity of care and to ensure optimal health management. In order to help achieve this, the client wants to supply providers and members with evidence-based information and resources by utilizing data management and feedback. The providers need to know who are their current members, members need to be educated on the medical home, and the management of care integrated. The information system must manage raw data, convert it to a uniform format and report the information to multitude of different audiences. The client required the system to analyze the complete data set each month it was updated and identify the members required care management. These members would then be further screened by a care manager so that each one received evidence based interventions. The software would need to report the progress of clinical interventions on regular basis. The client needed the product to provide reports of membership for each PCP, a web-based directory of the provider network, and integration with a contact management tool. Each member would need to be contacted upon enrollment into the medical home.

Solution
The solution provided by Deerwalk is a Management Information System (MIS) which serves to setup, operate and monitor ‘Medical Homes’ development. The MIS system receives eligibility files from South Carolina DHHS, captures referral information and relates to care management protocols. Not only does it handle the import of data, it also provides an interface through which the data can be manipulated and further information can be added. The most essential part of the application is the report generation tool. A variety of reports that provide an insight into different aspects of the data can be generated which can be further used for analysis and decision making purposes.

Benefits
The main advantage that CMH provides is the ability to handle all parts of the process in the same application (manage network providers, care coordination activities, report and data analysis). The organization’s efficiency has increased being able to use one system for their work processes rather than paper and/or multiple unrelated computer programs. Integration of the data within the system allows for sharing of information between application modules no longer requiring users to re-enter the same information in multiple locations, nor to jump from system to system searching for member information.

The system developed fosters sharing of information and coordination of care without the traditional functional “silos”. PCPs, Care Coordinators and staffs of the Medical Home can all work within the same system and share information across their functional groups. Studies have shown that coordinated health care is more cost-effective and results in better patient outcomes overall.

Apart from generic benefits provided by its architecture, the application has the ability to integrate claims data from other systems with the data collected by the Care coordinator to get a comprehensive picture of the beneficiaries across the health care continuum. This rich cache of information about an individual allows for proactive identification of members at the greatest risk and timely initiation of evidence-based interventions. Outcomes and periodic movement toward meeting established goals can be monitored and interventions modified as needed.

The Deerwalk developed system provides reports both for internal program evaluation and for use with external customers such as the State. The reports integrate key data elements from disparate sources to produce actionable data. In addition, the system allows the client to export data to other reporting platforms and to their own internal data warehouse; there are a multitude of reports to draw conclusions based on evidences and the patient demographics. Management of providers using these reports is a one click job.

Products and Services used

• Grails
• MySQL Server
• Tomcat Server
• jQuery

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