Population Health

BPCI Challenges Solved

When facing the challenges of care management and engaging with high-risk patients, doing business as usual may do more harm than good.  Perhaps the greatest challenge is the rapid identification of those patients who qualify for Bundled Payment for Care Improvement (BPCI) initiatives. Your organization runs the risk of missing the required touch points in the post discharge setting if the patients are not identified early. This could lead to unnecessary readmissions and loss of the incentives and worse yet, fines for not meeting the BPCI requirements.

IR1S Population Health incorporates the aggregation of patient data across multiple health IT sources in a facility or enterprise, the analysis of that data into a single patient record, and ultimately making that data actionable for various providers across the ecosystem, resulting in improved clinical and financial outcomes.

Bundle Payments for Care Improvement (BPCI) initiative

Identification of BPCI patients at admission is crucial to the success of a BPCI initiative. Additionally, following those patients easily and efficiently post discharge is equally challenging and important. 

Let R1 find the patients who meet the BPCI criteria that your facility participates in. R1 can greatly simplify the process of identifying BPCI patients without scores of staff and create a seamless handoff post discharge. Put us to the test!

“I need to integrate outpatient CDI as part of my Population Health strategy… and I don’t know where to start”

You can’t hire enough people, and cost justify it, to review every outpatient encounter. Let IR1S find the patients whose RAF scores are in jeopardy of declining for you and prioritize those for review by your CDI team. R1 can combine clinical and coded data across the longitudinal record to help you manage your patient populations, without having to have enormous staff.

“I need Dr. Jones to document the ________ next time Jane Doe comes in. She had________ last year and now it’s not in the record”

Fill in the blank, and let us find the records… and consider it done!  Need we say more? Our sophisticated rules engine identifies year of year HCC omissions and regressions, identifies unspecified codes that if specified are HCCs and pinpoints RAF regressions.

Sticky notes don’t work all that well in software – but R1 NOTES do. In population health management, collaboration is key, and you can’t collaborate if communicating is cumbersome; so, we make it easy for CDS, Coders, CM/UR, Quality, and even physicians, to communicate within the platform. Keep it simple.

A fully customizable query workflow is ready for you to integrate into your workflow should you decide to do so. Have as many Query forms as you wish, and design them as you wish, and integrate them into your workflow. Send communications between modules when utilizing out integrated tools to collaborate on queries prior to issuing them if you like.

Oh, and they won’t disappear when we upgrade your software — promise.

HCC Monitoring Tools

In the world of Shared Savings, identifying and capturing chronic conditions (HCCs) across the inpatient and outpatient settings presents additional challenges as most EHRs don’t satisfy the requirement for a true longitudinal history. Increase HCC capture and reduce RAF leakage through the most sophisticated HCC monitoring tools available.