Care Management/ Population Health
Where smaller physician groups cannot afford care coordinators for the Medicaid/Medicare population, Primo MSO has the appropriate scale to offer that service to its client groups.
Our Care Coordinators have cultural or linguistic expertise. Some focus on transitioning care from acute facilities to lower levels, ensuring that necessary supplies and equipment are provided. They also perform practical medication reconciliation for recently discharged hospital patients to help prevent readmissions. Other case managers monitor identified members at high risk of hospital admission or declining health without this service.
Effectively managing large patient populations requires collecting and analyzing precise patient data, clinical information, social determinants of health, and physician performance metrics. Although many information sources are available to physicians, there is often insufficient time and resources to integrate and assess this data for improved patient care and outcomes.
Primo MSO provides IT systems designed to identify sub-groups of patients within a larger population, such as obese diabetics or seniors with three or more co-morbid conditions. We analyze access and outcomes to determine best practices that can be communicated to the treating physician, resulting in improved care and patient experience.
Additionally, we employ predictive analytics to identify at-risk patient subpopulations. This allows clinicians and care coordinators to intervene proactively, helping to prevent patients from becoming chronic, improving medication adherence, and coordinating care more effectively. This information empowers physician organizations to develop outreach strategies and manage the daily workflow of patient care, ensuring that patients receive the necessary preventive services.
We can also support physician practices by leveraging their data to create real-time information dashboards. This enables physicians to quickly assess their patient populations and determine necessary preventive measures based on risk scores and medical histories.