Patients with complex needs often require services from a variety of social, medical and government benefit agencies. While there are some systems in place to coordinate referrals between providers, some key issues remain.
- There are no warm handoffs between providers.
- There are no feedback loops between referring agencies.
- The system lacks sufficient accountability between providers across the continuum of care.
- Critical data points get lost between visits because information and referrals are not shared.
By calling upon experts with a combined 50+ years of experience serving vulnerable patients with complex needs, we have developed several strategies to address these issues holistically. The solution involves the following elements.
- Resource and visit referrals built into the care plan.
- Integrating data and technology to build the safety net for vulnerable populations.
- Care plans that are shared between providers, across systems.
PCIC’s Unified Care Continuum Platform provides the solution by streamlining referrals and incorporating Social Determinants of Health into medical, social, and behavioral patient data and shared care plans. If you’re curious and want to learn more, please introduce yourself here.
Last modified on Tuesday, 26 March 2019 13:48