Managing Care in Distributed Healthcare Systems
Coordinating, delivering, and managing care in a fragmented healthcare system is tough. So many moving parts and so much information to gather and process from different providers, payers, government agencies, and other organizations. InterSystems is addressing these challenges with InterSystems HealthShare Care Community software.
HealthShare Care Community is a solution for care givers, 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 HealthShare Unified Care Record.
Users of HealthShare 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, HealthShare Care Community enables you to focus on the patients most in need, or entire cohorts susceptible to gaps in care.
Facilitating Care Planning and Communication
HealthShare 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 HealthShare Care Community are HL7®FHIR® (Fast Healthcare Interoperability Resources)-enabled, allowing the care team and care management to seamlessly share care plans, documents, and other information through HealthShare.
Care Team Identification and Management
HealthShare Care Community enables you to identify and manage one or more care teams for patients. Using HealthShare 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. HealthShare 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.
Creating and Sharing Care Plans
HealthShare 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.
Proactive Care Team Communication
With care team members and their roles and contact information clearly identified, HealthShare 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 to care plan changes as well as upon a patient’s admission, discharge, or transfer (ADT) event. 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.
HealthShare 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.
High- and Rising-Risk Cohort Management
HealthShare Care Community helps the care team and healthcare organization focus on improving care for patients most in need of care coordination. With HealthShare 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, HealthShare 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 HealthShare Unified Care Record, from the Documents section of the HealthShare Clinical Viewer
- For patients, via HealthShare 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 nonnetwork electronic medical records
- Offline, in print or PDF format, when online access to HealthShare 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
- 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
Extend the Value of HealthShare
HealthShare Care Community complements other HealthShare products, such as:
- HealthShare Unified Care Record, which aggregates and normalizes patient records from disparate systems across your organization, and outside it, to ensure that HealthShare Care Community and everyone using it can see a complete picture of the patient’s health
- HealthShare Health Insight, which identifies high-risk populations in need of help with transitions of care and care coordination outside of the acute setting
- HealthShare Personal Community, for patient access to their complete medical record, care plan, and clinician-patient communication
When you select HealthShare, you get more than technology. You also get our acclaimed customer support. See InterSystems.com/support to learn more.
Take the Next Step
To learn more about HealthShare Care Community, go to InterSystems.com/care-community or see InterSystems.com/offices to find contact information for your local InterSystems team. More information about HealthShare and its family of products is available at InterSystems.com/HealthShare.