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Clinical Integration & Disease Registry
The HPHO Board is pursuing chronic disease management as the cornerstone of the clinical integration initiative, relying on a Disease Registry Tool managed by MedVentive's Population Manager (TM) to collect and analyze data and help physicians manage the care they provide more efficiently. The registry uses evidence-based guidelines for outpatient care delivery, and measures care provided by HPHO physician practices against those guidelines. The registry helps physicians identify opportunities for improvement, and HPHO staff is committed to rewarding high quality medical practices. An HPHO clinical integration case manager works with physician's practices to help patients adhere to recommended care guidelines.
The HPHO disease registry currently tracks care provided to patients with the following chronic diagnoses:
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Coronary Artery Disease
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Congestive Heart Failure
Additional initiatives being pursued as part of the HPHO Clinical Integration Program:
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Post-partum depression: Ob/Gyn practices use screening tool to identify presence/severity of depression in post-partum patients. Patients identified with depression who cannot or will not seek care from a behavioral health specialist are treated by the Ob/Gyn providers according to an evidence-based treatment guideline developed by depression specialists at the Institute of Living (IOL) in concert with the Ob/Gyn providers. For patients whose care needs fall outside the guideline, IOL providers who specialize in treating depression are on-call to provide consultation services to the Ob/Gyn providers.
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Surgical Site Infection: Working with community-based surgical practices, HPHO measures surgical site infections that are not identified until after the patient leaves the hospital and presents for a follow-up visit in the surgeon’s outpatient office. Data is analyzed to identify overall rates of infection and patterns of infection that can be addressed through quality improvement initiatives.
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Readmission Demonstration Project: HPHO Clinical Case Manager reviews all patients admitted to Hartford Hospital who are covered by one payor’s commercial and Medicare Advantage plans. The case manager develops and implements post-discharge care plans to minimize the likelihood of avoidable readmission within thirty days of discharge from the hospital.
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Medical Home Demonstration Project: HPHO Clinical Case Manager is available to support HPHO practices participating in a medical home demonstration project by working with patients with chronic disease diagnoses to help those patients achieve optimal control of their chronic conditions.
For more information contact:
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