InterSystems Care Community

Coordinating, delivering, and managing care across a fragmented healthcare system isn’t easy. With countless moving parts and endless streams of data from providers, payers, government agencies, and community organizations, it’s a constant challenge to see the full picture - and act on it. InterSystems is addressing these challenges with InterSystems Care Community™ software.

InterSystems Care Community is a solution for caregivers, patients, and their families to improve communication, care transitions, and care coordination outside of the hospital setting. The whole care team – from patients and physicians to care managers and home health workers – can create a comprehensive care plan with the benefit of real-time access to the InterSystems Unified Care Record.

Users of InterSystems Care Community can document information relevant to a patient’s treatment – such as clinical, demographic, and social determinants from across the care continuum – in a shared care plan. By leveraging this information at the point of care, InterSystems Care Community enables you to focus on patients most in need, or on entire cohorts susceptible to gaps in care.

InterSystems Care Community is electronic medical record agnostic, and its information can be embedded within users’ native workflows. It ensures that patients will have an accurate care plan that follows them wherever they receive care, and that everyone on the care team is on the same page. All features in Care Community are HL7®FHIR® (Fast Healthcare Interoperability Resources)-enabled, allowing the care team to seamlessly share care plans, documents, and other information through HealthShare®.

InterSystems Care Community enables you to identify and manage one or more care teams for patients. Using Care Community, everyone on the team can see who is involved in the patient’s care; when they’re involved; what role they serve; and their contact information. Care teams can include members already known to HealthShare, and additional care providers that may just be working with a particular patient.

Care Community has a configurable option that allows clinicians to add other clinicians and/or other care team members as active members of a care team. This means that, even when a patient’s care team is made up of staff who don’t all work for the same organization, or are non-traditional care professionals (e.g. community transport service, local clergy), the entire assigned team can actively view, document, and proactively take actions to help the patient achieve the goals of a care plan. Care Community protects your investment in time and resources with the ability to share care team information with other health and care providers using a variety of interoperability standards, including HL7 FHIR.

InterSystems Care Community enables role-based administrators to create care plan forms with a choice of multiple custom form elements. Depending on the status of the care plan form – draft, active, or final – care team members can access the plan to update or contribute new information. Team members can import key data like a patient’s medications from the Unified Care Record directly into a care plan form.

Once a plan is marked final, it’s published as a PDF file for access by the patient and other authorized users. If needed, care team members can compare care plan versions to pinpoint changes. Team members can also flag if a care plan contains errors or should discontinue. Care Community will move any plans marked with errors to the Audit Log, and any discontinued plans to the Finalized plans tab.

With care team members and their roles and contact information clearly identified, InterSystems Care Community simplifies care team communication. The collectively created and updated care plan itself is the primary means of communication and coordination. Care Community can automatically notify team members of care plan changes or when they’ve been assigned a task, as well as upon a patient’s admission, discharge, or transfer (ADT) event. Additionally, patients can be notified of a request to contribute to the care plan or of changes made by the care team. These and other notifications make it easier to keep everyone on track with the plan. Through the HealthShare clinical message center, person to person communication among team members is saved for future reference.

InterSystems Care Community provides a library of discrete data elements which can be exported into the Unified Care Record’s data model and accessed for reporting. Elements include demographic information such as a patient’s primary language, social information such as a patient’s living arrangement, and care plan-specific information such as a patient’s goals.

InterSystems Care Community helps the care team and healthcare organization focus on improving care for patients most in need of care coordination. With Health Insight or other analytics tools, you can identify patients in high- and rising-risk populations and customize care plans accordingly.

With the power of InterSystems HealthShare behind it, Care Community presents a simple solution to complex care management problems. Healthcare systems and their partners can move forward as a team to improve health outcomes, close gaps in care, and increase care team efficiency. Key features include:

• Quick and easy access to the care plan:
  
  • At the provider point of care, within the context of the patient’s complete medical and social history
  • For users of the Unified Care Record, from the Documents section of the Clinical Viewer
  • For patients, access via patient portal, such as InterSystems Personal Community
  • With secure web-based access for care givers and patients in any setting, and access to care plans by external systems, such as non-network electronic medical records
  • Offline, in print or PDF format, when online access to Care Community is not practical
• Flexible templates enabling care team members to quickly establish a new care plan document and:
  
  • Capture structured and unstructured information
  • Add required questions
  • Add conditional ‘if, then’ logic
  • Assign care plan tasks to a specific care team member
  • Create task workflows to provide team members with clear directions on next steps
  • Designate questions or care plan sections for patient contribution
• Creation of a new template by copying from an existing care plan
• Centrally managed care plans that multiple care team members can share
  
  • Team members can view all tasks, across all patients, on one screen
• Capture of patient preferences and social determinants of health, including personal information the patient wants care givers to understand
• User audits, including date and time stamp, for traceability of all actions on the care plan

InterSystems Care Community complements other HealthShare products such as:

• InterSystems Unified Care Record, which aggregates and normalizes patient records from disparate systems across your organization, and outside it, to ensure that Care Community and everyone using it can see a complete picture of the patient’s health.
• InterSystems Health Insight, which identifies high-risk populations in need of help with transitions of care and care coordination outside of the acute setting.
• InterSystems Personal Community, for patient access to their complete medical record, care plan, and clinician-patient communication.

InterSystems Care Community can be deployed on premises or as a fully managed service.

When you subscribe to InterSystems Care Community Managed Services, InterSystems designs, hosts, and delivers the integration platform so you do not need to purchase, operate, secure, and maintain the infrastructure yourself. InterSystems Care Community Managed Services, include:

• All data center resources, including hosting, hardware, and network capacity needed to run the solution
• Ongoing maintenance of all solution components
• Customer-specific configuration and implementation services to bring the solution live, including building connections
• 24/7 support for the solution including real-time monitoring
• Seamless upgrades
• Sophisticated security and data protection programs

InterSystems Care Community is backed by InterSystems acclaimed customer support and extensive educational opportunities.

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Disclaimer: InterSystems® software, associated services, materials and expertise may utilize artificial intelligence capability and functionality. Please refer to the InterSystems Transparency Notice, AI Guidelines, Product-specific Documentation and the applicable Statement of Intended Use for more information.InterSystems Corporation: One Congress Street, Boston, MA 02114-2010, USA.