Chronic Diseases

Deliver coordinated and integrated care to prevent hospitalizations

Use Cases

Chronic Diseases: deliver coordinated and integrated care to prevent hospitalizations

85%

of people elderly people live with chronic conditions

~ $1500

could be saved annually with adequate care coordination on chronic patients management

Problem

Fragmented care is making providers spend too much with avoidable interventions, and patients experiencing poorer outcomes

Care integration is an unequivocal necessity for today's health systems, creating opportunities for transforming people’s experiences of care from disjointed to coordinated, reactive to proactive, and service-orientated to personalized. However, as it is not well stablished yet, patients feel lost in complex care journeys and providers spend too much time and resources with preventable emergency admissions and hospitalizations that could be avoided with timely interventions.

Solution

Connect the dots for everyone with a continuous, multi-level, multidisciplinary care journey

Decision support for diagnosis and treatment, to upskill generalist physicians and deliver self-sufficient primary care;

Decision support for referral criteria (from prevention to palliation), to always have the patient at the right level of care;

Automatic patient stratification through validated questionnaires and scores, that route the patient to the right care setting depending on risk;

Automatic follow-ups using an omnichannel approach with automatic identification of red flags, to conveniently detect patient deterioration ahead of time;

Patient progress monitoring in real time shared with multi-level care teams, providing a single source of truth for the patients needs and history;

Patient empowerment on self-care and autonomy to report disease deterioration, to increase care plan adhesion and participation as well as to anticipate health needs;

Interoperability capabilities linking different systems, to reduce repetition.

Benefits

Anticipate care needs to avoid decompensation;

Reduce unnecessary hospitalizations or admissions in the ED;

Reduce high-cost healthcare;

Optimize allocative efficiency (keep teams focused on differentiated tasks and high risk patients);

Improve patient experience.


Use cases on Chronic Diseases

Map and implement comprehensive care journeys, support referrals and extend patient experience beyond traditional silos and care settings.

Hilly Robot

Chronic Diseases

Heart Failure

Improve patient stratification, keeping patients on track.

Hilly Robot

Chronic Diseases

Diabetes Mellitus type 2

Improve patients' experience and help them adjust their insulin dose.

Hilly Robot

Chronic Diseases

Asthma

Increase capacity by identifying patients who really need care.

Hilly Robot

Chronic Diseases

Gastroesophageal Reflux Disease

Optimize the gastroenterology time and prioritize severe patients.

Hilly Robot

Chronic Diseases

Rheumatoid Arthritis

Enable patients to identify emergency episodes.

All pathways

Disclaimers and references


References

Ref: de Bruin, S. R., Versnel, N., Lemmens, L. C., Molema, C. C., Schellevis, F. G., Nijpels, G., & Baan, C. A. (2012). Comprehensive care programs for patients with multiple chronic conditions: a systematic literature review. Health policy (Amsterdam, Netherlands), 107(2-3), 108–145. https://doi.org/10.1016/j.healthpol.2012.06.006

Ref: Frandsen, B. R., Joynt, K. E., Rebitzer, J. B., & Jha, A. K. (2015). Care fragmentation, quality, and costs among chronically ill patients. The American journal of managed care, 21(5), 355–362.


Clinical disclaimers

This example is just for illustration purposes. It presumes an institution/hospital is looking for ways to improve care coordination and integration in a specific context in which clinical decision support systems can be a tool to help healthcare professionals achieve that indirectly. UpHill Route does not claim any direct clinical benefit leading to patient hospitalizations’ reduction.

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