Strive Health, based on the values, the supplier of kidney care, noticed many of his IT providers for health, such as the supplier itself, he acted widely in the space -based care space and cooperates with responsible care organizations and care systems.
Challenge
The models of these systems must manifest themselves in the technology and flow of Stive work, and Stible had difficulty finding a technology supplier that could ensure this unique case of operate of the required supplier.
This caused the need for staff to build their own technology compared to buying it. They needed a tool that helped in everything, from identification, which patients should be part of which care paths while lifting Modeling of data sciences and machine learning to understand what patient care features best adapt to the part of the Stible Care Model.
Employees wanted technology that was possible to configure and can be integrated directly with tools that are already used by the kidney heroes – nurses, nurses, social workers, care coordinators and dietitians trained to ensure highly specialist care and understanding of the complexities of kidney disease. In addition, the technology had to be malleable, because employees still learn what works.
“It is best to have such a property to be able to update and update all elements of the basic data model or user interface as soon as possible,” said Matthew Tempa, technology director at Stible Health. “We never want our activity to be able to introduce innovations faster than our technology, which is why ownership control is key.”
APPLICATION
The logic of risk stratification, which is used by many other sellers of care -based care, are looking at a much wider population, which is why they usually identify all patients with chronic kidney disease in slow stage (CKD).
“Our proposal and our technology have tried to focus, it is identifying the most risky patients in this group on which we can have the greatest influence,” Temba explained. “We wanted to operate our technology to develop individualized care plans for people with CKD, leading them on a care path that raises this problem early – preventing the progress of dialysis or transplantation.
“The first large song The VBC challenge solution concerned the patient’s identification and determining who the late CKD patients are and the final kidney disease (ESRD), who would benefit from our intervention the most, “he concluded.” Our logic of risk stratification identifies those who need a more intense care team. “
After identifying, the staff could then better deal with the health of these patients, giving them vigorous days at home, reducing their management of the operate of healthcare by keeping patients outside the hospital and generating joint savings, focusing on this preventive care through a value -based care model.
“In addition to being more precise in terms of risk stratification, the second song makes sure that our technology is integrated with our operations and presents data, analyzes and care plans for our care team in the existing flow of work,” Temba noted. “In this way, our care team knows that a patient who is completed in terms of risk will require more care, and can be prepared with the right mind when he is approaching this patient.
“Care teams can therefore use their clinical judgment along with the risk of risk to respond to the right sentence to the patient,” he added.
Fulfillment of the challenge
The created health of technology is called CAREMULTIPLIER. Aggregates and standardizes data from many sources and uses a package of predictive analytical models that support deep insight into the profiles of patient data from the kidneys.
“The model has always concerned building technology for our internal care teams and our kidney heroes who are our main users,” Temba explained. “In this way, all our staff addressed to patients-from nurses and medical assistants after care coordinators and social workers-use non-standard work flows we built.
“The user interface, with whom they engage on a daily basis to manage documentation and manage their care activities, is part of our technology, as well as data modeling and the risk profiles we create are embedded in this environment,” he concluded.
The model is also integrated with several other systems, such as Salesforce, AWS (which is used as a cloud provider) and AdvancedMD, electronic health documentation system. When nurses take care of and have to create a claim, they perform this documentation in AdvancedMD.
“To perform these tasks, our kidneys have a direct influence,” Temba said. “As an IT team, we enable them the best rating for every patient. This also has a lot to do with improving work flow and providing them with information and insights, and to enable them to be filled so that when they talk to the patient, all this information is easily accessible and basic to operate.
“By covering these technologies, healthcare organizations can improve performance and regain time in everyday operations to take care of the patient,” he added.
RESULTS
At the beginning of 2024, Stible Health introduced a modern flow of work, which had a huge impact on the initial time of documentation, shortening it in almost half. This created more time for the heroes of the kidneys with patients, not just gathering information about the assessment.
“This year we have a lot more work on how to make our time even more valuable, i.e. the KPI indicator with which we are still following,” Temba informed.
“We can also look at the effectiveness of our risk stratification model to show hard results,” he continued. “This is one area that we always follow and improve. Our machine learning environment allows us to tune our models when we get new patients, which makes another area in which we always focus on new development.”
Due to the observations and analysis of data, CAREUMULTIPLIER provides care teams, Stible achieved a 36% reduction in 30-day hospital readmissions, 49% reduction of hospitalization among high-risk patients, as well as by 67% augment in the optimal start-planned start of kidney replacement therapy.
“One example is our work with Oak Street Health,” recalls Temba. “Throughout our relations with them, they trusted that we are doing more and more transitional care management (TCM). This is a testimony of what they saw in our work flows. They saw our team as an organization that has been doing TCM for many years, which enabled their trust in our TCM program on our common patients.”
Tips for others
“Other organizations of healthcare suppliers should have a long-term worldview, although the company occupies a lot of investment capital to have this luxury,” Temba announced. “There are many external factors in the game and you must have organizational involvement. Non -standard building of technology adapted to the operating and clinical model of the startup organization is full of uncertainty.
“Organizations must think about how to build multiple use technology that is extremely flexible,” he concluded. “Finding this proper balance and more important, ensuring relationships with operational teams and clinical teams is really strong, so there are strict feedback loops, is crucial for success.”
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