The new Care Tool from North Shore-LIJ Care Solutions helps maintain the health of high-risk, New York State Health Home Medicaid enrollees.
Care Solutions oversees the health system’s care management strategy and operations, said Kristofer Smith, MD, Care Solutions’ vice president and medical director. As Nassau, Suffolk and Queens counties’ designated lead Health Home since 2012, Care Solutions serves more than 2,700 Medicaid recipients with complex needs. The Health Home model includes a clinical resource specialist, a social worker and a nurse care manager for every member.
Care Tool’s proprietary system helps this team coordinate care and services with a range of providers and community organizations to ensure enrollees can access all the services they need to stay healthy and avoid preventable hospitalizations. North Shore-LIJ’s technical teams worked with Care Solutions to base the tool on the InterSystems HealthShare health informatics platform.
By automating routine data-gathering and creating a shared workflow, Care Tool helps users from call centers to clinicians to manage the complexity of delivering services across the continuum of care.
“One of the keys to managing high-risk patients is an interdisciplinary approach. Care Tool gives all care team members an electronic environment to collaborate and coordinate efforts to help patients meet their health and wellness goals,” said Vishwanath Anantraman, MD, chief information architect of North Shore-LIJ and leader of the Care Tool development project.
The tool enables real-time medical decision-making to aid in needs assessment, workflow support and quality metrics for continuous improvement.
For example, Health Home staff members receive alerts as members are admitted for emergency or outpatient Lenox Hill NS App needs within health system facilities.
Furthermore, Care Tool lets the team monitor not only the number and types of patient/caregiver interactions, but also their quality and content. Moreover, it indicates the urgency of interventions that are most likely to affect good outcomes, such as appointments with primary care physicians, connection to family and group support. This helps the team prioritize and use Health Home resources to the best advantage.
“I love the Care Tool,” said Jennifer Baltusis, Health Home outreach coordinator at Care Solutions. “It’s intuitive and makes so much sense. One of the best things about it is being able to make changes to patient and provider information in real time. It’s extremely helpful that we can work with Care Tool in the field.”
The initiative has already resulted in productivity gains, Dr. Anantraman said. He added: “Prior to rollout, care managers had to be trained on multiple electronic health records [EHRs] to manually locate and integrate patient data. Now, they have all the information in one place, prepopulated for them on one screen. Information they enter in Care Tool is available to the entire care team.”