North Shore-LIJ Care Solutions Implements Care Tool to Coordinate Care for Medicaid High-Risk Populations

Care Tool
North Shore-LIJ Care Solutions will demonstrate Care Tool at HIMSS15’s Interoperability Showcase in Chicago.

GREAT NECK, NYNorth Shore-LIJ Care Solutions, a division of New York’s largest integrated health network, the North Shore-LIJ Health System, announced it has successfully implemented the North Shore-LIJ Care Tool to improve care for high risk, New York State Health Home Medicaid enrollees. The Care Solutions team leverages Care Tool's proprietary, cutting-edge technology to ensure collaborative, coordinated care. 

“North Shore-LIJ strives to be on the forefront of care management and value-based payment reform,” said Kristofer Smith, MD, vice president and medical director of North Shore-LIJ Care Solutions. “Care Solutions oversees North Shore-LIJ's care management strategy and operations, including executing full risk, shared risk, and shared savings contracts with government and commercial payers.” 

North Shore-LIJ is the designated lead Health Home for Nassau and Suffolk counties in Long Island, as well as the Queens borough in New York City. Since 2012, North Shore-LIJ Health Home has grown to serve over 2,700 Medicaid recipients with complex needs.  Health Home is a patient-centered care management service model that coordinates access to services to help Medicaid enrollees stay healthy and prevent avoidable hospitalizations. The Health Home model includes a clinical resource specialist, a social worker and a nurse care manager for every member enrolled in the Health Home. These healthcare professionals work as a team, and coordinate with a range of providers and community organizations, to ensure patients can access all of the services necessary to stay healthy and avoid preventable hospitalizations.

Innovative Care Tool Technology 
To address the complexity of delivering services across the continuum of care, North Shore-LIJ's technical teams partnered with North Shore-LIJ Care Solutions to develop the innovative electronic care management solution called Care Tool. The solution was built on the InterSystems HealthShare® strategic health informatics platform, which provides the interoperability and data management capabilities to leverage large volumes of claims and electronic health record (EHR) data spanning all venues of care.  The Care Tool automates routine data gathering and creates an optimal workflow to actively engage users – from the call center to the clinician. 

“One of the keys to managing a high-risk patient population is an interdisciplinary approach.  We created Care Tool as an electronic environment where all members of a patient’s care team can collaborate and coordinate efforts towards helping patients meet their health and personal wellness goals,” said Vishwanath Anantraman, MD, chief information architect of North Shore-LIJ, who led the development of Care Tool. 

Care Tool includes a rule-based system for real-time risk stratification to identify high-risk patients, as well as needs assessment, workflow support, and quality metrics for continuous improvement. For example, Health Home staff receive real-time alerts for members who are admitted for emergency or outpatient needs within the health system’s facilities. 

The Care Tool allows the team to monitor not only the number and types of interactions, but also the quality and content of those interactions. The Care Tool demonstrates the time sensitivity and urgency of interventions that are most likely to affect good outcomes, such as appointments with primary care, connection to family, and group support. In this way the Care Tool helps the team priority set and utilize Health Home resources to best advantage. 

Response to Care Tool
"I just wanted to say how much I love the Care Tool,” said Jennifer Baltusis, Health Home outreach coordinator of North Shore-LIJ 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.” 

“We are already seeing productivity gains from our investment. Prior to the rollout of Care Tool, care managers had to be trained on multiple 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.” Dr. Anantraman added. 

Learn More at HIMSS 2015 

NorthShore-LIJ Care Solutions will demonstrate Care Tool in the ONC/FHA area at the HIMSS15 Interoperability Showcase, Booth 2084, April 12-15, 2015 in Chicago. 

Dr. Anantraman and Beth Friedmann, RN of North Shore-LIJ will also discuss the Care Tool application at InterSystems Booth #961 at HIMSS15. Their presentation, entitled “A Platform for Success with Care Management,” is scheduled for Monday, April 13, 2015 at noon, and Tuesday, April 14, 2015 at 3:00pm. 

About North Shore-LIJ Health System
North Shore-LIJ Health System is one of the nation’s largest health systems, delivering world-class clinical care throughout the New York metropolitan area, pioneering research at The Feinstein Institute for Medical Research, a visionary approach to medical education highlighted by the Hofstra North Shore-LIJ School of Medicine, and healthcare coverage to individuals, families and businesses through the CareConnect Insurance Co. Inc. North Shore-LIJ cares for people at every stage of life at 19 hospitals and more than 400 outpatient physician practices throughout the region. North Shore-LIJ’s owned hospitals and long-term care facilities house more than 6,400 beds, employ nearly 11,000 nurses and have affiliations with about 10,000 physicians. With a workforce of about 54,000, North Shore-LIJ is the largest private employer in New York State.  For more information, go to

Media Contact:
Catherine Marenghi, InterSystems      
781-715-7310 (m)
[email protected]

Media Contact:
Betty Olt
516-465-2645 (w)
[email protected]

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