In today’s health care environment, coordination of patient care can be extremely difficult. Many physicians face a juggling act, trying to balance management of high-risk patients, attention to utilization and referrals, and leadership of care coordination teams. The deluge of metrics and systems can be overwhelming.

ACG System user Wiseman Innovations, a health care technology company focused on enhancing continuity of care, met these challenges by creating a user-friendly tool to streamline coordination of care and provide actionable analytic insights at the point of care.

Wiseman Innovations’ care coordination platform, the 360 Ribbon, is powered by the ACG System and connects physicians directly to care managers—a crucial step in identifying high-needs patients and enrolling them in a care coordination program. This tool makes metric review and referrals easier than ever for physicians and other providers because it operates within their existing Electronic Medical Records (EMRs), so they don’t have to learn a whole new system just to make a referral.

So how did they do it? Wiseman Innovations created a novel opportunity score based on the Johns Hopkins ACG System’s markers and risk scores. The score was designed to improve the likelihood of a patient enrolling in a care management program and experiencing better results during the care journey. Wiseman’s opportunity score is built to allow providers the quick insights into conditions they can address in the primary care setting such as Emergency Department visits, hospitalizations, care coordination concerns and frailty, while integrating into existing practice workflows and EMRs. The resulting opportunity score combines known information, historic utilization patterns and ACG-driven predictive markers into a single, easy-to-use indicator of patients who would benefit the most from the care management or care coordination programs.

Once this platform was implemented, the results were clear: patients referred via the 360 Ribbon, enrolled in the care management program and optimally managed for at least three months, reduced medical expenditures by 23% (or $239 a month) while enrolled in the program. Patients were able to improve medication adherence and generally remained compliant with their care plan, too.

Ultimately, Wiseman Innovations utilized the ACG System to create a user-friendly tool that seamlessly integrated into an existing EMR system, making it easier than ever for providers to assess and refer patients to care coordinators. Best of all, facilitating this connection between providers and care coordinators led to cost savings and better patient care.

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