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Care coordination in population health management helps improve outcomes

This integrated approach streamlines the sharing of relevant information about the patient to providers and staff across physical and mental health, as well as primary and specialized care. Care coordination also helps providers manage a case across the patient’s entire journey of care, from the initial point of interaction to follow-up and outcome reporting.

It is generally accepted that increasing coordination of care and referral management improves overall outcomes for patients, as evidenced in a technical review conducted by Stanford-UCSF Evidence Based Practice Center. Improved coordination helps organize care activities for patients and facilitates a more patient-centered approach to care across multiple providers, resources, and activities. It also allows for a more streamlined and efficient exchange of information between both providers and patients.

Current challenges to streamlining implementation of care coordination

Despite the benefits of care coordination, shifting towards a more patient-centered and integrated approach can be challenging for public health agencies, providers, and other stakeholders along the care journey.

While care coordination is beneficial for patients and helps providers understand the broader patient journey, implementation can be difficult. Some of the difficulties stem from fragmented systems and technology that can’t bridge the gap between different care providers, electronic health records, and a historically fee-for-service healthcare model.

Fragmentation can present barriers, for example, if a public health agency or health organization utilizes a case management system and set of digital tools that is not shared as part of a centralized system. This makes integration difficult, not only between internal and external teams, but even between internal teams that might be working on different aspects of the same case with no way to integrate and update relevant case information. The resulting redundancy and creation of silos makes it difficult to understand outcomes and report on the entire case more broadly.

How technology can be used to facilitate improved care coordination

In recent years, there has been a shift towards patient-centered and team-based care to better understand the patient’s overall journey. With this, technology can be an instrumental tool to help overcome some of the key challenges to not only coordinating care, but to facilitating referrals and connections.

Successful care coordination relies on the ability to ensure that all members of the care team, patients included, feel a shared sense of responsibility. It also requires digital tools used in the process to be engaging, easy to use, and useful.

Some of the key areas Chorus can be impactful in developing digital tools for care coordination include:

• Tools to build staff capacity by automating workflows
• Tools for mobile team management and coordination to assist staff in the field
• Tools for reporting that include centralized outcome reporting, as well as customizable dashboards and reports for individual teams
• Tools to create individualized care plans that patients and providers can collaborate on and share along the care journey

Chorus provides off-the-shelf modules with the flexibility of a no-code platform

Chorus enables implementing change quickly through off-the-shelf modules, while providing the no-code platform needed to create new tools uniquely suited to your community needs. Getting technology right means building off of existing best practice modules for efficiency while maintaining the flexibility to extend and tailor technologies to meet the unique needs of a given community.

At Chorus our no-code platform enables health agencies and organizations to rapidly create and deploy custom solutions that meet their unique needs for care coordination including case management and outcome tracking. At the same time, our suite of off-the-shelf modules can be used as a starting point to handle common needs such as building workforce capacity by digitizing clinical workflows, case management, resource availability, and staff scheduling.

We think this is the modern, agile way that technology can be an integral and flexible part of an ever evolving public health and clinical care system.

For more information about the Chorus platform, please connect with our team today.