Patient Centered Medical Homes (PCMHs)

Identify AND close gaps in care, empower your care manager

Care Team Connect’s integrated care management platform powers your Patient Centered Medical Home (PCMH) to consistently deliver the right care to the right patient at the right time, resulting in a sophisticated and efficient care coordination network.

Care Team Connect supports PCMHs by enabling providers to coordinate care at the practice level to close care gaps  that have been identified via integrating numerous data sources including traditional claims data and real time data from EMRs, hospitals, and pharmacies. While analysis can help you identify the gaps, the ultimate goal is to close the gaps and feed that information back to the registry/analytics solution to improve quality of patient care.

Care Team Connect’s emphasis on patient-centered care plans results in a team based approach to care that includes physicians, behavioral health providers, community partners, and many other providers. The shared patient-centric care plans driven by best practice protocols codified in the Care Team Connect platform enables appropriate resource utilization and enhanced communication among the different providers and the patients / families.

The platform is a powerful tool for the Care Manager to build a better relationship with both the patient and the providers and keep track of a large patient population in a resource-efficient manner. Care Managers leverage the platform’s ability to automatically identify high-risk patients who meet the programs criteria using real-time data, create a patient-specific care plan with tasks, goals, and alerts, and invite the patient’s care team (including the patient and family) to actively participate in the plan.The ability to include patients (and families) in the care team, define and manage patient’s goals, educate on health and wellness are only a handful of features that empowers the patient to be more involved in their care management. At Care Team Connect, we understand that managing patients is a journey and we are there to support you in the longitudinal care of a patient.

PCMH care managers will have the workflow solutions to turn data and protocols into coordinated care and executives will have reporting to determine program effectiveness and outcomes. The end result – a streamlined care coordination platform linking the PCMH team, patients / families, and different care providers to achieve better patient outcomes while managing costs.

Contact us to learn about the story below and the impact we have made on other PCMH clients.

Client Story

Our client manages a care collaborative and initiated a PCMH program in partnership with a major payer in the state. They sought a solution to create a state-wide, patient-centric shared care plan for all patients and operationalize their care collaborative to enable physicians, nurses, acute care facilities, sub-acute provider and community programs to work as a team to improve patient outcomes. Our client selected Care Team Connect because they needed not just a technology partner, but a development partner that would grow and evolve their solution as they evolved with demonstration and shared risk programs year over year.

The Care Team Connect platform is a key component of their Patient-Centered Medical Home (PCMH) provider-directed care management efforts. Care Managers leverage the platform’s ability to automatically identify high-risk patients who meet the programs criteria using real-time data, create a patient-specific care plan with tasks, goals, and alerts, and invite the patient’s care team (including the patient and family) to actively participate in the plan. Once care gaps are identified, the workflow component of the platform helps in closing the care gaps and helps our clients stay on top of the quality requirements.

In addition to the core functionality, the platform integrates directly with multiple payer systems, a local Health Information Exchange (HIE), and hospital HIS systems, enabling the direct import of various forms of data. File logic automatically assigns primary and secondary insurances, alerting care managers to eligible and non-eligible patients upon attribution file changes. Real-time triggers are coded into the system for care plans and protocols, and matching and exception reports can be generated to resolve any discrepancies.

Care Managers have access to over two dozen standard reports required by payers and other sponsoring entities. Care Team Connect’s program development experts facilitate the training of additional provider partners. The platform s that as the patient population increases, our client will have the resources on hand to scale their care management efforts accordingly.

With Care Team Connect, our client has grown over time to managing many Patient-Centered Medical Homes, adding employer populations, and ensuring that patient outcomes improve which helps in growing their business.