Socio-demographic insight to complement clinical analytics

Add socio-demographic risk insight to traditional clinical indices to enhance care management and post-discharge success. Early insight to a patient’s daily situation outside the hospital is critical to successful care transitions and readmission management. EMR and population health platforms capture clinical elements but come up short on the socio-demographic. Solution includes:

  • Patient’s overall socio-demographic readmission risk measure
  • Patient’s underlying factors driving elevated risk for care team targeting
  • Integration into your electronic health record or care management system
  • Suitable for acute settings as well as clinic and ambulatory
  • Available on admission and updated throughout hospitalization
  • Model does not require clinical information
  • Targeted work lists tied to care management strategies
  • On-screen notifications and flags
  • Activity and intervention notices and tracking
  • Ongoing performance analysis, benchmarking and improvement planning

At-risk agreements require providers to become patient utilization managers over time and across settings. Success in managing the acute care phase can quickly be undone with a few extra days in a skilled nursing facility or by an unplanned readmission to the hospital. Uncertainty and risk can extend for 30, 60, or 90 days, depending upon the bundle. During that time, patient compliance with a treatment plan is dependent not only on their clinical recovery, but also the factors which constitute their daily life. A lack of transportation can adversely affect physician access and medication compliance. Financial challenges could necessitate care and treatment tradeoffs for a patient. Understanding these issues early and intervening in a targeted manner is critical to bundled payment program success.

Configures to Your Specific Environment

Connance solutions are delivered through a secure cloud-based optimization platform that integrates predictive analytics, a rules engine, work listing, and performance reporting with patient and partner engagement modules.   Work in your existing system – connect to your existing workflow tools in EPIC, Cerner, Siemens, MEDITECH and many others – or utilize Connance’s platform as your team’s work listing, collaboration and workflow tool.