Hospital care coordination units and health plan care management teams typically are responsible for monitoring patients who are receiving care in the home. This likely means reviewing data from EMRs or looking at claims-based data.
Dina CEO Ashish V. Shah says there’s a better way for these groups to connect with home-based providers.
“A lot of what happens in hospitals, SNFs and primary care settings can now happen in the home, but the infrastructure is not in place to coordinate services in that environment or to have visibility into what’s happening,” he said.
Shah recently spoke to Home Health Care News about his vision for “care traffic control,” a model that helps hospitals and plans have greater visibility into the care that’s being delivered in the home.
“When all the services are brought to you, there’s an extra degree of difficulty to keep everyone on the same page and deliver the very best service for the individual.” To do this successfully, he said, data is pulled from three sources:
-Coordinating hospital-at-home or SNF-at-home services like durable medical equipment providers, physician house calls, and medication delivery.
-Engaging with patients or families to pull back real-time feedback on how they’re doing at home.
-Using artificial intelligence to help manage by exception and gain an understanding of what individual patient or member needs look like.
You can listen to the interview “Care Traffic Control: Connecting Hospitals and Plans to the Home” below.
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