The HealthyCircles™ Medical Home Solution

Apr 30 13:21 2011 Adam S. Pellegrini Print This Article

he HealthyCircles Connected Health Platform makes the vision of the Patient-Centered Medical Home a reality. This is possible as HealthyCircles helps a primary care practice connect physicians, patients, families and other members of the Care Team in order to provide continuous, coordinated and comprehensive care. 

The HealthyCircles™ Medical Home SolutionTHE HEALTHYCIRCLES SOLUTIONThe HealthyCircles Connected Health Platform makes the vision of the Patient-Centered Medical Home a reality. This is possible as HealthyCircles helps a primary care practice connect physicians,Guest Posting patients, families and other members of the Care Team in order to provide continuous, coordinated and comprehensive care.   HealthyCircles provides advanced primary care practices with the care management tools needed to focus on what matters, “Taking better care of more patients, more efficiently.”  This is a flexible care management solution that embraces the joint principles that underlie this approach to medical care.2WHY HEALTHYCIRCLES?Physician practices who utilize the HealthyCircles technology can qualify for additional health plan bonuses such as Bridges to Excellence, comply with the Medicare Physician Quality Reporting Initiative (PQRI) and qualify for additional payer incentives linked to Medicaid Medical Home services. Physicians can generate additional revenue by providing professional services such as care transition monitoring, population health management, eConsults and wellness coaching to patients via HealthyCircles.MEETING NCQA DESIGNATIONThe HealthyCircles Connected Health Platform provides a flexible, modular solution that is designed to enhance the ability of advanced primary care practices to adopt the patient-centered medical home model, qualifies them for the NCQA designation and most importantly, helps them to focus on what matters most- providing the best clinical care to the patients and communities they serve.MEETING THE NCQA’S PPC-PCMH STANDARDS AND POINTS WITH HEALTHYCIRCLESNCQA’s nine standards are listed below along with illustrations on how HealthyCircles maximizes a practice’s ability to fulfill the Must Pass Elements. Practices that use HealthyCircles can be reassured their patients will have a better care experience and better clinical outcomes.1. ACCESS AND COMMUNICATIONThe HIPAA compliant, permission-based and bi-directional invitation system enables communication and care coordination and care management between patients, families and members of the health care team. The Message Center enables practices to expand their capacity, embrace open scheduling and monitor patients continuously using connected medical devices. Each practice determines its own custom policies for access and communication.2. PATIENT TRACKING AND REGISTRY FUNCTIONSThe HealthyCircles Triage Dashboard enables practices to track demographic, clinical and real-time vital signs for patients within a practice and to sort patients by condition and disease management programs. This enables clinical reminders and population health management.3. CARE MANAGEMENTHealthyCircles delivers interactive Health Programs that are built upon Evidence-Based Clinical Guidelines for conditions such as CHF, Diabetes, HTN, asthma and cancer. Based upon responses to these Health Programs, physicians can create, deliver and modify the care plan based upon both medical and social determinants of health.4. PATIENT SELF-MANAGEMENT       SUPPORTPatients can be enrolled in customized disease management and wellness programs that are delivered dynamically by HealthyCircles to patients online, through mobile devices and by interactive voice recognition technology via the phone. The system is designed to foster communication and to support patients across the continuum of care.5. ELECTRONIC PRESCRIBINGHealthyCircles provides a full medication management system to drive medication adherence, to perform medication reconciliation and to monitor new medications for adverse effects. HealthyCircles can interoperate with currently installed ePrescribe technology or physicians can subscribe to Premium Modules available through the platform.   6. TEST TRACKINGTrackers enable a practice to perform exception management and to respond quickly to abnormal laboratory data such as blood glucose levels or abnormal vital signs such as uncontrolled blood pressures in real-time as well as to monitor those who are doing well to efficiently provide access to those patients who need urgent or immediate care.7. REFERRAL TRACKINGThe HIPAA compliant, secure, permission-based and bi-directional invitation system enables communication and care coordination and care management between patients, families and members of the health care team. The system supports eConsults, HIPAA secure e-mail messaging and captures the information shared with consultants within the Electronic Medical Record system to enable billing for these services and to support clinical integration activities.8. PERFORMANCE REPORTING AND IMPROVEMENTA practice can monitor and generate reports on clinical outcomes and patient experience of care for individual physicians and other health care professionals participating in a Care Team.3  HealthyCircles can interface with registries currently used by a practice or physicians can subscribe to Premium Modules available on the platform.9. ADVANCED ELECTRONIC COMMUNICATIONSThe HealthyCircles Connected Health Platform, including the Professional and Consumer Portals, are at the   heart of the connected care platform and empower true patient-centered care that supports evidence-based, shared decision-making and care management support by physicians, members of the Care Team, patients     and their families. The HealthyCircles Professional Portal connects Health Care Professionals to their Patients. This Portal is designed to help the Health Care Professional deliver better patient care, to expand access to their services while optimizing practice efficiency. This Portal speeds the exchange of relevant health information across the continuum of care, allowing convenient access to Patient information, enables shared decision-making and offers new revenue-generating opportunities. Patients connect to their Health Care Professionals through the HealthyCircles Consumer Portal. This Portal includes a Patient’s Personal Health Record and Secure Messaging through which designated Care Team members communicate while interactive Health Programs and Services support care.  COMMON ELEMENTS OF A PATIENT-CENTERED MEDICAL HOMEAccess to a Personal Physician in a Trusting, Healing RelationshipHealthyCircles enables primary care physicians and advanced practice nurses to invite their patients to enroll in HealthyCircles in order to receive access to an integrated personal health record, secure Care Team messaging and to gain access to interactive Health Programs and Services recommended by their physicians. Consulting physicians and other health care professionals participating in the care of the patient can be invited to join the Care Team.Supports Team PracticeHealthyCircles enables all members of the Care Team to participate in efforts to embrace prevention strategies, to improve clinical outcomes and to lessen the burden of disease by aligning these goals among individuals who collectively are responsible for longitudinal and episodic care of patients. Whole Person OrientationHealthyCircles provides professionals with the care coordination tools necessary to support communication and the interchange of data between qualified professionals while providing a longitudinal patient health record that can be shared across geographic and institutional boundaries.Care is Coordinated and/or Integrated Across All Elements of the Complex Health Care SystemHealthyCircles seamlessly supports the flow of information across the continuum of care including the hospital, the ER, physician offices, long-term care and home health services. The Data Exchange Hub facilitates the sharing of information in a secure, HIPAA compliant environment with EHRs, state-based registries and disease-specific care collaboratives. Quality and Safety are Hallmarks of the Medical HomeHealthyCircles’ Care Solutions provides the ability of physicians to deliver evidence-based care through its integrated Health Programs, to deliver educational content to patients and to receive directed clinical decision support that is relevant to their patients’ unique needs and are linked to performance measurement. The Medication Wizard enables full medication reconciliation and tracking designed to avoid adverse drug events and to avoid associated hospital re-admissions and emergency department visits.Enhanced Access to CareHealthyCircles’ exception management system connects to home medical devices and mobile technology enabling medical practices to prioritize office visits for those who need urgent care and to coordinate care post-acute care discharge or for emergency department visits. PaymentHealthyCircles includes a legal medical record that enables physicians and health care professionals to capture their work in providing patient-centered care services. This includes the ability to deliver eConsults, to communicate using the fully integrated secure e-mail messaging and the ability to share information across the Care Team. The connectivity to remote medical devices enables physicians to manage patients with complex conditions at home. HEALTHYCIRCLES IS YOUR MEDICAL HOME SOLUTIONThe HealthyCircles™ Medical Home Solution means care delivery has no boundaries and distance from care no longer means disconnected care.¬¬¬¬¬¬¬___________________________________________  Qualify for designation as NCQA Physician Practice Connections-Patient Centered Medical Home Designation (www.ncqa.org).2 American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association. Joint principles of the patient-centered medical home. 2007 Mar. Accessed 2010 Sept 28.3 The technology supports practice-based clinical quality improvement efforts as required for Maintenance of Certification for ABMS. 

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About Article Author

Adam S. Pellegrini
Adam S. Pellegrini

Dr. Susan Nedza, a nationally recognized physician leader is the Vice President, Strategic Clinical Solution for HealthyCircles, LLC. Her broad experience as a board-certified emergency medicine specialist, as a Chief Medical Officer at the Centers for Medicare and Medicaid Services (CMS) and most recently as senior executive at the American Medical Association (AMA)

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