Strive Health, A Value-Based Kidney Care Provider, Noticed Many of its health it vendors, like the provider itself, operate extensively in the value-based care space and collaborate Care Organizations and Health Systems.
The challenge
These Systems’ Models need to be manified in Strive’s Technology and Workflows, And Strive was having a hard time Finding a technology vendor that would provide that counting required.
That spurred the need for strong staff to build their own technology versus buying it. They needed a tool that helped with everything from identifying which patients should be a part of which care pathways while leveraging Data Science and Machine Learning Modeling To undersrstand whats patient characteristics best align with parts of strong’s care model.
Staff wanted a technology that was customizable and outs be integrated directly into the tools already beyed by its kidneyheroes – nurse pradeses, nurses, Social Workers, Social Workers, Care Coordinators and dietitians trained to provide highly specialized care and undress the intricacies of kidney disease. Further, the technology had to be able to be flexible as staff continue to learn what works.
“It is best to have that ownership to be able to upgrade and update any components of eite Officer at Strive Health. “We Never Want Our Business to Be Able to Innovate Faster Than Our Technology, Why is why having openership control is key.”
Proposal
The risk strateification logic that many Value-based care vendors use looks at a much broader population, and so they are typically identifying all patients with late-statue kidney dishey diste.
“Our proposal and what our technology sought to focus on is identifying the most high-Risk patients with that group who we can have the Most The Most IMPACT on,” Tamba is expected. “We wanted to use our technology to develop individualized care plans for people with ckd, guiding it on a care path Transplant.
“The first big piece for Resolving the VBC Challenge Was Around Patient Identification and Figuring out Who the Patients with Late-STEGD CKD and ENNAL Disease (ESRD) Are who would be benefit the most from our intervention, “hestinued.” Stratifort Logic Identifies those those who need a more extended care team. “
Once Identified, Staff then Better Manage these Patients’ Health, Giving Them More Healthy Days at Home, Reducing Their Healthcare Utilization MANAGEMENT MANAGEMENT BY CEEGMENTS PATINS PATINES OTHEEPING PATINES OTHEEPING PATINE Shared Savings by focusing on this preventative care through a value-based care model.
“In addition to being more priority about the risk strateification, the other piece is making sure our technology is integrated into our operations and presenting data, analysis and care plans to our care team team team team white team white Existing Workflow, “Temba Noted. “This way, our care team knows that a patient is complex in risk is going to need more care naturally, and they can be prepared with the right frame of mind when they approve.
“Care Teams then can use their clinical judgment in concert with the risk striving to make the right judgment calls on the patient,” He added.
Meeting the challenge
The Technology Strive Health Created is Called Caremultiplier. It aggregates and standardizes data from a Multitude of Sources and Leverages a Suite of Predictive Analytic Models that Support Deep Insights Into Kidney Patint Data Profiles.
“The model has always been about living “This way, all of our patient-facing staff-from Nurse Practitioners and Medical Assistants to Care Coordinators and Social Workers-Are Using The Customized Workflows We’Ve living.
“The user interface they engage with on a day-to-day basis to manage documentation and manage their care activities is all part of our technology as well as the data modeling and Risk profiles we create ared Into That User Environment, “He Continued.
The model also is integrated with a less other systems, such as salesforce, AWS (which is used as the cloud service provider)And Advancedmd, An Electronic Health Record System. When Nurse Practitioners Deliver care and need to create a claim, they do that documentation in advance.
“To Accomplish these tasks, our kidneyheroes are the ones making a direct impact,” Temba said. “As an it team, we enable them to make the best judgment for Each patient. It also Conversation with a patient, all of that information is readily available and easy to use.
“By Embracing these technologies, healthcare organizations can improve efficiency and reclaim time in their daily operations to give back to patient care,” He added.
Results
At the beginning of 2024, Strive Health Rolded out a New Assessment Workflow That Made A Hug Impact on Initial Documentation Time, Cutting it almost in Half. That created more time for the kidneyheroes to spend with patients and not just collecting assessment information.
“We’ve Got a lot more work ahead of us this year on how to make their time even more valuable, which is a kpi we continue to track against,” Tamba reported.
“We also can look at the effectiveness of our risk strateification model to showcase hard results,” He Continued. “That is one area we’re alloys tracking and always improving. New Development. “
Because of the Insights and Data Analysis Caremultiplier Delivers to Care Teams, Strive Has Achieved A 36% Reduction in 30-Day Hospital Readations, A 49% Reduction in HOSPITALIZANS AMONGATIONS AMONGATIONS AMONGATIONS Patients, and a 67% Increase in Optimal Starts-A Planned Start of Renal Replacement Therapy by receiving a preparaptive kidney transplant, initiating home dialysis or initiating in-cancerous hemodilysis.
“One example is our work with Oak Street Health,” Temba Recalled. “Throughout our relationship with them, they have trusted us to do more and more transitional care management (tcm). That is a testament to what they saw in our workflows. Been doing tcm for many years and this solidified their trust in us to use our tcm program on our shared patients. “
Advice for other
“Other Healthcare Provider Organizations Should Have a long-sighted world, Thought it takes a lot of investment capital for a business to have that luxury,” Temba Advise. “There are multiple external factors at play and you have to have that Organizational Commitment to do IT. Custom Building a Technology To suit the operational and clinical model of a Startup Organization is one that is filled with uncerty.
“Organizations must think about how to build reusable technology that is extramely flexible,” He concluded. “Finding that right balance, and more important, ensuring the relationship with the operational teams and the clinical teams is really strong so there are tight feedback loops, IS Critical to Success.”
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