How do we do it?
Northwell Health Solutions is responsible for Northwell Health's care management programs to support physicians and patients in coordinating care and delivering quality outcomes. Care managers include nurse practitioners, nurses, social workers, and other staff who assess patients to proactively identify needs, educate patients, and work collaboratively with providers to coordinate services.
Services are tailored to meet the needs of different patient populations and individuals. Northwell Health Solutions provides in-person and telephonic care management for patients in the community, at physician practices, and after hospital discharge. Northwell Health Solutions also operates a 24x7 Clinical Call Center staffed by nurses who outreach to patients and address questions that arise after hours.
Northwell Health Solutions works closely with Northwell's information technology teams to develop the Care Tool software program. The Care Tool is integrated with Northwell Health's internal Health Information Exchange (HIE) platform that connects data from different Electronic Health Records (EHR) and insurance claims so that care managers and community providers have a centralized way to see a comprehensive view of each patient and document updates. This HIPAA-compliant, web-based Care Tool can identify high-risk patients, assess patient needs, create and share care plans, and alert providers to relevant patient events such as admissions.
The Northwell Health Solutions analytics team also uses proprietary and industry leading data analysis tools to understand Northwell's patients and to guide care management and outreach programs. Clinical, financial, and claims data are used to stratify risk cohorts, identify gaps in care, and measure performance.