Chronic Care Management (CCM)

We help you improve quality and reduce cost with proactive data, right in your hands.

For too long our care delivery system has predominantly been reactive in addressing patient needs. Successful value-based healthcare that simultaneously improves quality and reduces total cost of care requires a new care management paradigm --- one built on proactivity. But to be proactive you must have the right information at the right time at the hands of the right care provider:

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Right Information

By integrating clinical (EHR) and cost (claims) data into a single patient-centered view Clinigence equips care providers with all the information they need to be proactive in addressing patient needs. For example, effective management of diabetes patients requires access to most up-to-date lab results (e.g. A1c, LDL, etc.) and biometric data (e.g. BP levels) in addition to medication and procedure records. Similarly rich data sets are critical to all chronic disease management---representing the largest long-term opportunity to improve the value of care.

Right Time

Simply put, the earlier---the better. Clinigence leverages (near) real-time information to empower care providers to act as early as possible. For example, daily changes in weight provide early indicators of deterioration in heart failure patients that can be used to prevent (re-)hospitalizations. Another example, combining the right information and the right time is in the case of obesity, which may remain undetected for years in claims data but immediately recognized through BMI scores in clinical data. In this case early intervention is made possible well ahead of potential cardiovascular complications and diagnoses.

Right Care Provider

By integrating data from all care settings and systems and providing universal web-based access to comprehensive reports, Clinigence enables better coordinated and patient-centered care. This means that any care provider can see the right information at the right time, i.e. at the point of care as they address individual patient needs.

Patient Stratification - Risk Assessment and Predictive Modeling

Maximizing the effectiveness and efficiency of care delivery and management activities requires stratifying patients. Unfortunately, virtually all risk assessment methodologies in the market today do not incorporate clinical data from EHR systems. The reason: these methods were developed for healthcare payers with no or limited access to such data. The result: predictive models that may work statistically for very large populations, but remain highly inaccurate in predicting the needs of the individual patient.

Clinigence offers the CMS Hierarchical Condition Categories (CMS-HCC) model as a starting point for patient risk stratification. But we believe that value-based care management requires a new breed of predictive models---one that leverages our integrated clinical (EHR) and cost (claims) data set. We are working collaboratively with our partners and clients to develop and test such models and their ability to drive unprecedented effectiveness in care management.


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