2019 Best Practice Awards Submission for HIE/ADT Implementation
Each quarter, Wellcentive reports based on ADT data identify ED utilization by diabetic patients. These reports that also risk-stratify patients are sent to care managers in the six pilot practices. The reports are used to aid to the care managers to identify patients (high ED utilizers and high-risk diabetics) who would benefit from care management interventions. Care manager workflow includes addressing gaps in care, improved care coordination, addressing SDoH needs, establishing self-management goals to improve patient outcomes and reduce healthcare costs, and address appropriate use of ED.