TXCIN’s care model is built on the values of the three-part aim: better experience of care for individuals, better health for populations and lower growth in expenditures. TXCIN facilitates these aims in the following ways:
Real-Time, Web-Based Software
In order to succeed in the value-based care arena, TXCIN implemented real-time, web-based software to cut healthcare spending and enhance Medicare Beneficiary care. All participating TXCIN physicians use Dallas-based RevelationMD technology. The technology allows providers to see how they are performing in real time, in terms of quality and efficiency.
TXCIN’s technology solution will provide real-time information about Beneficiary conditions, test results, and immediate care needs of the aligned beneficiary population to support the delivery of high-quality, patient-centered care. These will serve to alert physicians and clinical coordinators to the Beneficiary’s care transitions and changes in health status, allowing the care team to conduct timely outreach.
Monitored Performance ComparisonReports and alerts have been developed to help individual physicians understand their own performance and how their downstream providers and supporting institutions are performing on their behalf. All reporting comes with comparison to themselves over history, comparison to their peers, comparison to market (where available) and impact on efforts towards improving population outcomes.
Identifying and Proactively Addressing High-Risk Populations
TXCIN’s ability to stratify beneficiaries by risk allows targeted outreach, improved care coordination, informed performance evaluation, and increased engagement.
Practice Tools for Success
TXCIN’s technology allows our participating members to review laboratory results, medical and pharmacy claims in real-time to identify Beneficiaries with select health conditions and apply a series of evidence-based rules criteria to identify gaps in patient care; patient adherence to clinical therapies; patient safety issues; unnecessary services and treatment patterns. It will also allow the physicians care plan and demographic information to identify Beneficiary preferences to account for individual patient circumstances.
Beneficiary and Community Involvement
Community resources will be leveraged to help Beneficiaries, in coordination with their physicians, optimize their understanding and compliance with programmatic efforts to improve their ability to achieve optimal health within their risk category. Clinical coordinators are critical members of the care team and act as liaisons between the Beneficiaries and families, providers and suppliers, and other community supports. As liaisons, clinical coordinators play the roles of care coordination, advocate, educator, mentor, coach, outreach worker, and translator.