Improving outcomes with a team-based approach to patient care
Hospitals, healthcare systems, and health plans are implementing team-based, patient-centered, care management programs to improve care quality and boost clinical outcomes. With a care management approach, extended multidisciplinary care teams—physicians, home health workers, community caregivers, family members, and others—work closely together to help patients manage their health needs outside the hospital. Care management programs are often used to support patients recovering from complex or chronic conditions like cancer or a stroke after they are discharged from the hospital and transition to in-home care.
Care management initiatives can help healthcare delivery organisations reduce hospitalisations and emergency room visits, avoid duplicate tests and non-essential medical appointments, and decrease population health risks and care costs. But sharing information and coordinating tasks across an extended care team is no easy matter. Care-team members often work for different organisations with different EHR systems and workflows. Each organisation may have a unique care management platform and distinct care plans. And some organisations may still rely on paper-based methods.
Disjointed systems and practices can impair collaboration and visibility, squander valuable time and resources, and compromise care quality and patient satisfaction. Even an individual enterprise (e.g., a large healthcare system with many different hospitals and EHR systems) can face these challenges.
Coordinating care across diverse organisations and settings
InterSystems HealthShare Care Community® makes it easy for extended teams to create, customise, update, and share comprehensive digital care plans. The HL7® FHIR®-enabled solution breaks down information silos and interoperability barriers, providing a common data model and consistent experience for all users. With HealthShare Care Community, cross-organisational care-team members and patients seamlessly exchange information and coordinate activities, in real time, from any location. The solution improves visibility for caregivers and allows patients to contribute directly to their care plans, increasing provider efficiency, patient satisfaction, and quality of care. HealthShare Care Community helps healthcare delivery organisations identify high-risk groups, evaluate the effectiveness of targeted programs, and focus resources on the patients most in need of care.
HealthShare Care Community
Benefits & Use Cases
- Improve care coordination and quality
- Boost patient experiences, satisfaction, and outcomes
- Reduce population health risks and care costs
- Identify and manage at-risk patient groups
- Prioritise staffing and optimise resources and provider productivity
- Move care out of hospitals and into communities
- Improve in-home care and remote patient monitoring programs
- Reduce unnecessary GP and ER visits, and hospital admissions
- Eliminate information silos and care gaps
UK National Health Service (NHS) Transforms Information Sharing with HealthShare Care Community
Lincolnshire NHS uses InterSystems HealthShare® to power an integrated care portal and, with HealthShare Care Community, to provide individualised care plans to local care teams and patients. The InterSystems solutions enable doctors, nurses, health practitioners, care providers, and care managers to efficiently share information and coordinate care from any setting. Care Community helps care providers save time and effort, and improve care quality and patient experience by providing full and instant access to accurate treatment plans and patient preferences. Clinicians use the care portal to review patient records and care plans in advance of visits, improving readiness and simplifying consultations and community-based visits. This approach helps the NHS improve population health and reduce care costs by moving care out of hospitals and closer to the citizens of Lincolnshire.
User Features and Capabilities
- Secure, web-based access for caregivers and patients in any setting
- Real-time notification of assigned tasks, changes to care plans, and patient events like admissions, discharges, and transfers
- Access to care plans by external systems, such as non-network, electronic medical records
- Print and PDF export capabilities for offline and external access
- Real-time access to care plans, with complete, accurate, up-to-date patient information
- Control access to care plans at plan level and question level
- Create simple-to-complex custom care plans
- Establish task workflows
- Include required questions and conditional logic
- Designate questions or care plan sections for patient contribution
- Capture structured and unstructured data
- Document patient preferences and social determinants of health
- Assign tasks to a team, a specific care-team member, or a patient
- Automatically assign a task to a care-team member upon patient contribution
- Send care plans to individuals or teams, in bulk
- Multiple team members, including patients, can share and contribute simultaneously
- Built-in versioning and reconciliation to prevent data gaps and inconsistencies
- Care-team members can view all tasks, across all patients, on one screen, from any location
- Log user actions and version changes for accountability and compliance
Platform Features and Capabilities
- EHR-agnostic platform
- Deploy on-premises, in a public cloud, or as SaaS solution designed, hosted, and managed by InterSystems for ultimate operational simplicity