Deliver Quality Care for Highly Complex Patients
Wanda has missed a third scheduled primary care appointment to include a blood pressure check. She has lived with hypertension for years. Her pattern of missing appointments more frequently is surprising, but there isn’t much that the practice can do aside from reschedule.
What the practice doesn’t realize is that Wanda has been diagnosed with dementia by the neurologist from another practice in the ACO. The two practices don’t share the same health record, and no one realizes that Wanda has missed blood pressure checks because her dementia has grown become more severe.. The primary practice now has a new challenge to manage the care for a patient with two complex conditions.
The missing blood pressure also has the ACO worrying about its future quality reporting – and preserving the savings money that should come back to the ACO. Although the ACO has traditionally scored well when it comes to blood pressure control, these results are based on a sample of patients. The new APP reporting requires longitudinal patient tracking, across all ACO practices.
The most medically complex patients are seeing a variety of specialty providers, often in different groups. Missing values for their conditions are easy to miss without a holistic view of the patient from the multiple practices. That makes treating them extremely difficult.
Missing values also lead to problems for meeting Value-Based Care quality reporting requirements, leading providers to fail requirements when, in fact, the data was available.
By matching patients across disparate sources of data, Roji Health Intelligence builds a comprehensive patient profile, enabling a holistic patient care plan, rather than a disjointed series of events and diagnoses.
Roji’s ability to integrate data from disparate EHRs also ensures that the ACO can accurately and completely fulfill its quality reporting responsibilities and preserve its share of savings.