A Patient’s Health Value Propositionsm is the lens through which we enable a person and their family see their health and implement its role in their lives while improving quality of care and reducing costs.
We enable, enhance and support a person and their family in choosing to increase valuable health-related behaviors and decrease harmful behaviors.
We operationalize the domains and dimensions of real-world social norms and their management.
Patent-Pending Patient’s Health Value Propositionsm
Our patent-pending approach helps manage the Patient’s Health Value Propositionsm enabling and supporting linkages and integrations among performance measures, Standard-Of-Care interventions and community supports by:
- Establishing a holistic view of a person and their family
- Capturing, collecting, analyzing, converting and medical-coding of the patient’s voice
- Collecting real-world data from a variety of sources, during the patient’s navigation of the pattern-of-life remote from traditional sites of care
- Managing real-world social norms measures
- Managing real-world data evidence and predictive and other analytics
- Interactively engaging the patient’s voice and its insights with the comprehensive care team
- Advancing the development and management of the patient’s comprehensive care plan by the care team informed by the patient’s voice
- Advancing the delivery of quality of care through performance measures as proxies for outcome measures
- Managing outcome measures inter-related among and linking the clinical-technology-business-administrative relationship through value-based contracting
- Implementing the delivery of care through our Advanced Lifestyle Management Instrument.sm
Supporting Performance Measures
(source: Greg Howe, Karla Silverman, Rob Houston; California Federally Qualified Health Center Alternative Payment Model Implementation Guide, March 2023)
Comparison: ECM; Complex Care Management; Population Health
Our approach integrates and manages Enhanced Care Management (ECM), Complex Care Management (CCM) and Population Health. While both ECM and CCM focus on managing complex patient needs, ECM is a specific tier within the broader CCM and Population Health frameworks. ECM is a more intensive and personalized approach specifically designed for the highest-need individuals within a population. CCM is a broader term encompassing care coordination for patients with multiple chronic conditions. Population Health looks at the overall health of a larger group and aims to implement preventative measures across the entire population, not just high-risk individuals.
Key Differences:
- Focus Population: ECM targets the most complex patients within a population, often including those with multiple chronic conditions, social determinants of health issues and high healthcare utilization, while CCM may include a wider range of patients with complex needs, but not necessarily the absolute highest need individuals.
- Care Coordination Level: ECM typically involves a dedicated Lead Care Manager who actively coordinates all aspects of a patient’s care across different healthcare providers and social services, providing a more hands-on approach. CCM may involve a similar care coordination function, but with potentially less intensive oversight depending on the patient’s needs.
- Population Health Perspective: While both ECM and CCM can contribute to population health management, the primary focus of Population Health is on identifying and addressing health risks across an entire population through preventative measures and targeted interventions, whereas ECM is specifically focused on managing the most complex individuals within that population.
Integrated Case Management
Our Integrated Case Management consists of intake, eligibility and entitlement, evidence management and participant management.
Evidence Management
Our Evidence Management supports the evidence lifecycle (design, collection, verification, activation, correction, sharing). Administration is optimized by reusing appropriate evidence elements over multiple programs. Care programs decide the types of evidence that can be shared and the parameters for sharing.
Participant Management
Our Participant Management involves many participant individuals and organizations. Participant types play a role in the delivery or receipt of services. HET Participant Management stores a set of information for each participant type, including common information and extra information.
Business Intelligence And Analytics
Our Business Intelligence and Analytics provides decision supports by analyzing the effectiveness of programs and gaining insight into the efficiency of their operations. Community-based information is complimented with traditional analytics models in establishing predictive compliance management.
Outcome Management
Our Outcome Management enables the creation and management of outcome plans for patients and their families. HET Outcome Management helps assess needs, establish goals, plan for goal attainment and track progress. HET Outcome Management supports collaboration and coordination of resources and delivers a complete understanding of patient needs and barriers to success.
Provider Management
Our Provider Management helps manage providers holistically, resulting in improved service delivery, enhanced efficiency and sustainable outcomes. HET Provider Management provides a common repository of information, reusable business services and enhanced accessibility for caseworkers and external providers.
Enterprise Collaboration
Our Enterprise Collaboration enables multidisciplinary collaboration among programs where multidisciplinary teams are involved in supporting the needs of patients and families, including agencies, local providers and interested community partners.
Integrated Care
Our Integrated Care is a HIPAA-enabled, cloud-based, software-as-a-service platform that aggregates data and connects stakeholders, unlocks and integrates the full breadth of information from multiple systems and providers, automates care management workflows and scales to meet the demands of growing populations under management.
Integrated Care supports the coordination and delivery of services that empower care teams to:
- Understand and address the psychosocial determinants of a person’s overall health and their clinical issues
- Integrate various analytics solutions to consolidate data from disparate systems and risk-stratify populations
- Curate data from historical notes, similar individuals, structured data sources and multidisciplinary care programs
- Associate such curated data with specifications
- Recommend the optimal combination of structured programs, best practices and personalized insights
- Design and update individualized care plans
- Manage care spanning multidisciplinary teams and programs
