A premier academic health system’s cardiology division takes best practices and AI to scale with a care navigator-led remote care clinic.
Challenges
The health system faced increased volume of chronic disease patients and wanted to ensure best practices would be adhered to by providers. Also, they wanted to improve adherence to care plans and value-based goals that require cost reduction through fewer office visits.
Solutions
One of the nation’s largest and most respected hospitals, internationally acclaimed for excellence in clinical care, wanted to create a platform to provide software-guided decision making for care navigators.
Required capabilities included:
- Identification of patients with specific clinical characteristics
- Screening and enrollment of patients into relevant programs
- Continuous live access to clinical data in the EMR
- Inform proactive and periodic outreach by care navigators for patients for coaching and treatment guidance related to labs and medication adjustments
- Support navigator-driven remote care for hypertension, heart failure and lipid control
