Building Connections on the Care Continuum

The health information exchange created via the medial home project opens up a window to patient activity outside the practice as well, Moore says, adding she can now receive reports of subspecialty care via the exchange. A centralized care management team was also assembled, Ashline adds, to help physicians better coordinate care among high-risk patients. This group includes a nurse, social worker, pharmacist and I.T. support staff. "When a patient is admitted and identified as needing support, the nurse will visit the patient in the hospital and make sure there is good follow-up after discharge," Ashline says. The care management team can also help physicians at the practice level, scouring the EHR for at-risk patients and contacting them to come in for testing. Care managers will be granted access to both the practice EHRs and the data exchange as the project unfolds, Ashline adds.

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