The Diary is pleased to announce a healthcare organization has signed on to pilot The Diary CarePro™, a provider application for value-based chronic care management. The five-person Care Team supports patients with chronic conditions in their journey to better health.
Currently, the group has recognized significant obstacles to providing optimum care:
- Disjointed systems force care coordinators to waste time searching through multiple EHR’s, documenting in multiple locations and flipping through binders of notes to gather critical information
- Incomplete patient information; siloed systems, no real time data and a complete lack of social determinant data (one of the most important factors in health care outcomes).
- Inability to to track productivity and outcomes,
- Barriers to sharing information within care network
The initial pilot will be care team focused with a patient roll out scheduled for a later date. Care Coordinators of varied skill sets and backgrounds will use CarePro’s Today feature, along with data from The Diary app, to quickly determine if their patients have completed their daily health goals. Care items and tasks are created and adjusted by the patient or care coordinator based on needs—giving providers the opportunity to modify treatment plans in real time to best advance their patient’s progress. Over the course of the Pilot, we expect an improvement in workflow efficiency and, improved patients outcomes.