Population Care Flow

The Population Care Flow application provides end-to-end program management for care teams and their patients. Using program management capabilities, care teams can qualify patients, coordinate outreach and care program enrollment, and create baseline assessments. They can also actively manage and coordinate care by creating care plans, assigning goals and interventions, documenting care, and managing medications. All members of the care team can access a longitudinal patient record to view past encounter information, problems, goals, barriers, patient activities, and interventions.

This Care Flow application walks members of the care team through the process and enables them to coordinate care for a patient.

The problem

Care teams distrust black-box care management technology—with algorithms that aren’t transparent or flexible, processes they can’t adapt to rapidly changing circumstances, and fractured data and workflows from different sources. Care teams need flexibility and transparency in an end-to-end solution built to support the entire clinical care pathway.

Care management doesn’t work in isolation. All members of the care team must be engaged in the care management process: ED nurses, front desk staff, outpatient pharmacists, patients, etc. Many care management systems fail to provide clear transitions and collaboration between members of the care team.

Our approach

The Population Care Flow application includes an integrated set of care management functions that enable all care team members across the community to effectively coordinate care and manage the needs of their patients. Care team members can easily qualify and enroll patients in the right care management programs, create baseline assessments and care plans, document care notes, and access the same longitudinal patient record to view past encounter information, activities, and interventions—no matter where the care was provided. Care Flow leverages the world-class data and analytics in the DOS™ platform—and all workflow activities flow to the DOS platform so the data is available for outcomes analysis.

Benefits and features

• Improve quality of care and gain efficiencies – An end-to-end, streamlined workflow for everything from patient enrollment, active care management, patient records, and care coordination between all care team members saves time and improves care. 
• Include patients in multiple care programs – The patient-centric approach enables care teams to have patients engaged in multiple care programs at the same time—and monitor the patient’s overall care and care programs.
• View aggregated disparate claims and EMR data – An analytics-driven DOS platform aggregates disparate claims and EMR data to provide a comprehensive patient view.
• Collaborate to improve treatment for the patient – All care team members have access to a longitudinal, patient-centric view so they can track progress, identify barriers, share results with clinicians, and more.
• Secure the patient’s privacy – A flexible security model includes both role-based permissions and a patient access policy.

Use cases

• A care team is collaborating to improve their processes for managing patients with diabetes. Their goal is to streamline care management workflow activities and improve the overall efficiencies of the care management team members. With the help of Health Catalyst teams, they start by evaluating baseline estimates of time for each management task and identifying opportunities to limit variation and documentation. Health Catalyst helps the team define goals and configure the application to align with their needs. After launching Population Care Flow, they notice a significant time savings for each task. Not only does their process time improve, they are also better able to match the right care managers to the right patients, share patient information for all care team members, and facilitate communication between care team members.
• A multidisciplinary team has a complex patient with multiple diagnoses. Because all members of the care team (nurse navigator, social worker, therapist, pharmacist, etc.) have access to the patient’s longitudinal record, the therapist notices that depression is becoming more prominent. The therapist discusses the patient with the team and takes over as the care team lead for this patient. He creates and monitors the care plan—and sends the care plan to the patient’s primary care provider.