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Many depend on the ecosystem that provides physical, mental, social, substance use, spiritual care, and other services in their neighborhood. Learn how whole-person care solutions can improve care coordination and outcomes across your community.
Better whole-person care for your community
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Maria's mother begins post-release clinical recovery services that are aligned with the pharmacy so she can receive medically-assisted treatment (MAT) prescriptions.
Maria’s mother is released and assigned care at the rehab center.
Pharmacy
This level of care coordination could not be possible without a fully integrated behavioral, primary care, human services, and foster care health IT solution.
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Maria enters a foster care program. In addition to visiting the local federally qualified health center (FQHC) for a proper health evaluation, the caseworker suggests Maria see a child therapist at the certified community behavioral health clinic (CCBHC).
A social services caseworker assigns Maria a guardian.
CCBHC
FQHC
Foster Care
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Maria’s mother has a substance use disorder—she recently was arrested and booked at the correctional facility.
Maria lives in a rough household.
Corrections Facility
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John’s PCP reviews the Consolidated Clinical Document Architecture (C-CDA), his last psychiatric visit, as well as pharmacy data in the ePrescribing module of the EHR. This provides the PCP the information needed to address John’s follow-up needs.
The PCP retrieves a clinical summary.
Pharmacy
This level of care coordination could not be possible without a fully integrated behavioral and physical health EHR and practice management solution.
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His PCP wants to see if John is still being seen by a psychiatrist at the clinic. According to staff records, John hasn’t been showing up to his appointments.
John’s PCP contacts the local certified community behavioral health clinic (CCBHC).
CCBHC
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John’s primary care physician (PCP)
has started a new diabetes medication and wants to see how things are going. However, the
PCP notices John is experiencing acute symptoms of psychosis.
John arrives at the local federally qualified health center (FQHC) for a follow-up visit.
FQHC
ACHIEVE BETTER OUTCOMES >
Research has shown that
only 20% of health outcomes
can be attributed to clinical care.
Whole-person care relies on the ability to integrate behavioral health, primary care, human services, and foster care data in one place.
Maria is a five-year-old
who experiences trauma as a result of her mother's substance use disorder.
MEET MARIA >
John is a 58-year-old who suffers from both type 2 diabetes and schizophrenia.
MEET JOHN >
DATA SHARING
WHOLE-PERSON CARE
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Direct messaging through the EHR enables the CCBHC to exchange Consolidated Clinical Document Architecture (C-CDA) and start John on a better path forward.
The CCBHC uses direct messaging with the local hospital.
Hospital
The ability to share health information between separate health entities allows for effective care coordination resulting in optimal patient outcomes.
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John’s CCBHC
connects to a HIE.
Through the health information exchange (HIE), the certified community behavioral health clinic (CCBHC) accesses important emergency department visit information.
CCBHC
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John thinks he is having a heart attack, but a quick diagnostic check reveals he is experiencing a panic attack instead. John is discharged.
John checks himself into the emergency department.
Hospital
ACHIEVE BETTER OUTCOMES >
30% of health outcomes are the result of healthy behaviors such as diet and exercise.
Data sharing is key to helping you meet client needs and achieve business goals.
Maria is a five-year-old
who experiences trauma as a result of her mother's substance use disorder.
MEET MARIA >
John is a 58-year-old who suffers from both type 2 diabetes and schizophrenia.
MEET JOHN >
POPULATION HEALTH MANAGEMENT
DATA SHARING
WHOLE-PERSON CARE
POPULATION HEALTH MANAGEMENT
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Antonio can now understand what services the FQHC can provide and at what costs via post-adjudicated claims data fed through the population health management platform.
The FQHC can visualize how to better serve client needs.
FQHC
Claims data insights are great way to get informed about where clients receive services and other healthcare activity.
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This information informs what care costs are across the community to treat certain client cohorts.
Antonio collects post-adjudicated claims data.
Public Health Dept
Hospital
CCBHC
Pharmacy
Social Services
Outpatient Mental Health
Corrections Facility
Rehab Center
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By way of a population health management tool, critical service utilization information can be gathered and risk stratification conducted.
Antonio seeks to bring payer claim files into the federally qualified health center system.
FQHC
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Dr. Hersh and her staff work with the Public Health Department to build a team of community health workers or "navigators" to conduct targeted interventions across the community.
Dr. Hersh’s program connects with other entities via an HIE.
Public Health Dept
Integration of population health analytics with your EHR is the most effective way
to deliver insights where they’re needed—in the workflow at the point of care.
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The health IT solution can create geo “hot spots” to identify individuals who have high-risk scores, co-morbidities, medication non-adherence,
and severe mental illness.
Dr. Hersh uses a Population Health tool to stratify risk.
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As an initiative to build healthier communities, Dr. Hersh and her staff create an Outreach Program.
Dr. Hersh provides care at the local federally qualified health center (FQHC).
FQHC
ACHIEVE BETTER OUTCOMES >
50% of health outcomes are influenced
by a person’s physical environment, in other
words, social and economic factors—also known as Social Determinants of Health.
Population Health solutions gather and analyze client data from multiple sources and deliver actionable insights to the point of care.
Antonio, a clinical data analyst, uses post-adjudicated claims data to understand how to reduce care costs.
MEET ANTONIO >
Dr. Hersh, a primary care physician, and her care team use population health management to build better community care programs.
Meet Dr. HERSH >
Hospital
Day Care
Foster Care
CCBHC
I/DD Home
School
FQHC
Pharmacy
Social Services
Crisis Response Van
Mobile Health
Outpatient Mental Health
Corrections Facility
Public Health Dept
Rehab Center
Care Worker & Homeless
WHOLE-PERSON CARE
DATA SHARING
POPULATION HEALTH MANAGEMENT
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Maria is escorted to her classroom to begin her education.
The school is
notified that Maria has been vaccinated.
School
The ability to share health information between separate health entities allows for effective care coordination resulting in optimal patient outcomes.
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Staff at the FQHC make a direct connection to the state immunization registry (public health department), which unlocks Maria’s vaccination information.
Maria’s vaccination records are not on file.
Public Health Dept
Maria’s school has no record of her vaccinations. The school contacts the local federally qualified health center (FQHC) where Maria is a patient.
Maria arrives
for her first day of kindergarten.
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FQHC
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EXPLORE THE HEALTHCARE ECOSYSTEM >
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