Deliver coordinated and integrated care to prevent hospitalizations
Chronic Diseases: deliver coordinated and integrated care to prevent hospitalizations
of people elderly people live with chronic conditions
could be saved annually with adequate care coordination on chronic patients management
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.
Map and implement comprehensive care journeys, support referrals and extend patient experience beyond traditional silos and care settings.
Gastroesophageal Reflux Disease
Optimize the gastroenterology time and prioritize severe patients.