Population Health Intelligence Platform

The platform integrates clinical data and other data from multiple sources and gives users easy access to diseaseregistries, gaps in care, predictive analytics, population risk stratification, hospital admission data and referral data. The powerful reporting engine tracks clinical outcomes, provides feedback to facilitate the management of individuals across the care continuum, and provides tools to effectively monitor individuals at all levels of risk. The platform also feeds our Population Health Portal, Participant Portal and Provider Portal.

Medical Management

Our Medical Management services combine people and information to create a highly personalized and effective approach to acute care management, chronic care management, utilization management and wellness. Accurate, integrated data is used to identify at-risk patients and analyze gaps in care, automate clinical workflows, track results and support continuous improvement. The result: patients experience fewer emergency and hospital visits and better overall health.

Risk Stratification

Risk stratification tools identify the sickest of the sick for appropriate prioritization, intervention and care management. This tool uses demographics, medical conditions, care patterns and resource utilization to stratify patients into one of five categories: healthy, healthy with conditions, chronically ill, high risk and episode of care. This facilitates medical management and physician decision-making, identifies clinical interventions based on governance decisions, promotes accountability, and assists in determining appropriate healthcare services.

Predictive Analytics

Our Predictive Analytics tool models medical conditions within a population and identifies potential high-risk patients before they need expensive care. It determines health risks by assessing past provider visits and medical conditions/diagnoses, major episodes of care, case and disease management activities, prescription and refill patterns, and clinical claims. Predictive Analytics help determine where medical dollars have been spent in the past and where they’re likely to be spent in the future.

Care Team Coordination

The goal of our Care Team Coordination services is to create a strong, collaborative team that includes the patient, personal health nurse, and the primary care physician and other specialists as needed. After assessing the patient, the care team creates a health and treatment plan to manage current conditions, address future issues before they become an episode of care and support health and wellness. The team is supported through our Population Health Management portal, which aggregates and shares information in real time, assists in implementing health and treatment plans, integrates protocols for prevention, and interfaces seamlessly with the electronic health record to foster effective collaboration.

Population Engagement

Our Population Engagement services lead the industry in getting patients actively involved as partners in their own health. By building supportive, long-lasting relationships, our personal health nurses achieve an 82-percent engagement rate with patients—compared to industry benchmarks of 25 percent initial participation and only 7 percent long term. Our success is based on using data to identify participant needs; fostering an active relationship among the nurse, patient and primary care physician; to the extent possible that the same nurse works with the patient and provides ongoing oversight even after an episode of care is closed.