Transforming Care Management
Steve Bleck [email protected] 617 548 5924
Steve Bleck: Sales Executive
Stacy Burda: Solutions Engineer
ClientTrack™ Care Coordination Platform for New Hampshire IDN’s
Transforming Care Management 2
20-year track record of case management for health and human services
SaaS based platform
Positioned at the forefront of the convergence of social services and healthcare: Social Determinants
We serve more than 1,300 clients across public sector, nonprofit, and for-profit organizations
Privately held company based in Salt Lake City, UT
Company Overview
Transforming Care Management
ClientTrack Platform:
Transforming Care Management Company Confidential 4
ClientTrack Data Management Tools use data to provide maximum flexibility for configuring the presentation layer
Transforming Care Management
Demo Agenda • Data Base Introduction
• Event notification
• Referrals- Select pre-populated client record through notification
• Referral Eligibility
• Create Referral
• Incoming Referrals (Closed loop referral)
• Portal (Close loop referral and Communication)
• Care Plan
• Edit Client Information
• Provider Associations
• Diagnosis
• Medications
• Consent
• PHQ9
• Goals
• Reporting
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Transforming Care Management
Implementation and Agile 2.0
Initial Iteration
Additional Iterations
Stakeholders are engaged often This allows them to see how requirements are implemented. Their feedback is used to refine design. As a result, the end solution is better than the first design.
Complete Solution
Engage
Solution Components High-Level Components required for System Plan
System Plan Start with a high-level roadmap
Con
Continuous integration from all developers/partners in order to discover incompatabilities as soon as possible.
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Care Coordination Use Cases for
Interoperability
SUD Care Coordination
Behavioral Health Referral
Transitions of Care
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HL7 Encounters
Admit/Discharge/Transfer (ADT) messages Admission,
Discharge and Transfer (ADT) messages are used to
communicate episode details.
• ADT messages carry patient demographic information
for HL7 communications, but also provide important
information about trigger events (such as patient admit,
discharge, transfer, registration, etc.).
• ADT messages are extremely common in HL7
processing and are among the most widely used of all
message types
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C-CDA
C-CDA templates are used to define clinical documents used for specific purpose like the CCD and Care Plan
Transforming Care Management
Product Roadmap
Product Roadmap 2014 2015 2016 2017 2018
Clie
ntT
rack
Cas
e M
anag
emen
t S
oft
war
e
Technology Initiatives
Releases
Partnership
established with
Microsoft for
leveraging IaaS and
PaaS (start with report
framework in PaaS
and plan for IaaS
options in 2017+)
Revenue Cycle
Management Phase I
Release: Validation &
Eligibility supporting
EDI transactions for
health care enrollment,
claims, and eligibility
using electronic
transactions in
ClientTrack's APIs
Development of APIs for ADT transactions and a CDA, common for care
coordination in ongoing accordance with ONC’s interoperability roadmap
2014 v5 HMIS Updates
deployed to ClientTrack
environments Sept ‘16
Continuous upgrades
to automate
engineering processes
Phased project to introduce modules using Azure
Converting to the use
of Azure Cloud
Storage to significantly
reduce storage costs
and allow for the
application to have an
interface to data
warehouse systems
Integration with Office 365 for calendaring and email
features
features
Machine Learning/Predictive Analytics project in conjunction with Microsoft
ClientTrackBI: separate
product that integrates
with Microsoft BI server
to provide clients the
ability to analyze and
view their data using
the Microsoft BI tools
ClientTrack Administration and Toolset Updates:
moving SQL Script functions into administrative
operations and refactoring forms engine to a
template-based architecture
Refactor ClientTrack
end user operations
by moving the current
case management operations into Azure
based application
Revenue Cycle
Management Phase II
Deployment
Continuous compliance updates including standards
for housing programs for youth and programs
focused on substance abuse and mental health
ICD-10, DSM, and the
implementation of
common health care
concepts including
problem list and
medication tracking
using drug database,
and encounter tracking
specifically designed to
support behavioral
health programs
Deployment of route
management to
support large food
delivery programs
Global search
capability added to
user interface to help
users find data and
features/functions with
one search
Addition of multiple access features allowing system
administrators to control users’ access to individual
features and tools for increased security
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Transforming Care Management
Functionality to Consider • Waitlist
• Housing: Prioritization and Eligibility
• Eligibility for Services
• Revenue Cycle Management
• Portal
• Assessment of High Risk through assessment data
• Social Determinants Assessments: Workforce, LTSS, Substance Abuse, Chronic Illness
• Appointments
• Service Tracking
• Form, Workflow, Eligibility, Query designer
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Transforming Care Management
Next Steps • Requirement Specification Workshops
• Define exact requirements
• Define phases and timelines
• Define integrations
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Transforming Care Management
ACO Case Study – Colorado RCCO
• Coalition of providers delivering outcome based services to more than 180,000 covered lives
• Pioneer in community-based, Medicaid-funded Accountable Care Organizations
• Leading the way for other similar organizations around the country
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Transforming Care Management
Community Coordination of Care Case Study - LA County Department of Health Services
Problem – disproportionate use of expensive healthcare resources by vulnerable populations in need of both health and social services
Solution - coordinate healthcare and community services through an electronic coordinated care system with inter-operable, bi-directional data feeds to further drive the goal of long-term housing stability and outcome driven healthcare
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Transforming Care Management
CLIENTTRACK PLATFORM
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Common Themes
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Emerging Trends
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