Precision Care Coordination:

Right task, right person, right time

The way we care for
patients is changing
A simple concept is gaining momentum in
healthcare: how can we effectively care for
a patient if we are not caring for the whole
patient? We know that quality health outcomes
are 40% driven by social and economic factors,
and only 20% by clinical care, yet 88% of the
healthcare spend in the United States is on
medical services1.

Our healthcare system is beginning to widen

the view of a patient’s needs beyond what
happens in an emergency room, clinic, or
doctor’s office. For many people, traditional
medically-focused interactions with their
healthcare providers are not sufficient because
they do not treat the personal, behavioral, or
financial issues in their life that may stand in
the way of achieving their full health potential.
The use of the phrase Social Determinants of
Health (SDOH) has become commonplace in
healthcare policy and strategy, evidence that
innovative care models should consider non-
medical issues such as nutrition, housing,
transportation, medication adherence, and The promise of precision
home assistance to truly influence outcomes
and the cost of care. care coordination
Care coordination is commonly delivered as a
To make this approach pervasive we must one-size-fits-all medical program. This approach
strengthen communication between all can result in delayed care, adverse events,
members of patients’ care teams – clinical, and complications for patients, contributing to
behavioral health, and social service – to $25-$45B in wasteful spending annually2. Two
ensure patients are getting the support they evolving healthcare trends are teaching us to look
need to improve their overall wellness and at care coordination differently:
quality of life. It should be easy for patients
and their families to stay engaged as • Population health efforts have defined
knowledgeable partners in their care plans cohorts of high-cost, high-need patients,
instead of being relegated to the role of and forced us to examine the root causes of
passive recipient of services. chronic disease and high utilization.

• Precision medicine efforts have shown that

treatments tailored to the individual patient
are far more effective at curing disease.

High-quality whole person care requires precision

care coordination: the deliberate organization of
medical, behavioral, and social care tasks, carefully
tuned to each individual’s health and social needs, at
any given point in time. Precision care coordination
can scale across populations because it ensures the ACT.md connects care
right task is assigned to the right person at the right
time - ideally when each patient is most likely to be teams, synthesizes
receptive to intervention. Technology ensures people patient data, and drives
and processes have access to just the right information,
share responsibility for the patient, and learn from coordinated action
all available evidence to continually refine best care
coordination practices over time.

The power of the health TRANSPARENCY

collaboration hub Provides visibility into the status
of all interventions and programs
ACT.md’s health collaboration hub is a secure, shared
for any patient plus the ability to
space where care coordinators can interact with
measure and follow-up
patients and care teams wherever they may be. It
brings together data from healthcare and community-
based organizations to create one real-time view of
each patient’s current plan of care. Care plans are built
through assessments, goals, tasks, and communication EFFICIENCY
shared between the patient and team members. ACT.
md powers precision care coordination by connecting Brings electronic workflows
all members of a care team – medical, social, and to care coordination activities
community – and integrating all aspects of care that are currently trapped on
coordination, which team members otherwise struggle paper, faxes and phone calls
to track, execute upon and measure.

INNOVATION

Enables healthcare providers

to experiment with, measure
and report on new models
of care

ENGAGEMENT

Connects patients and all

members of the extended
care team to align plans
and actions
 ACT.md connects
everyone on a patient’s
care team so they can
coordinate on effective,
comprehensive care plans
More effective SDOH
management
Over 80% of payers believe that addressing
SDOH of their member populations will
improve their population health programs.3
Many value-based models of care will soon
be measured on the effectiveness of SDOH
assessment and interventions. Integrating the
social determinants into healthcare delivery is
new and closing the loop on SDOH referrals is
hard to manage.
ACT.md transforms SDOH management.
Our automation library provides flexibility in
creating and changing workflows that bridge
medical and non-medical services. Care
teams can capture patient assessment data
electronically and coordinate and track the
social interventions that improve a person’s
overall stability and well-being. When an
assessment shows that a patient does not
understand nutrition basics, or that a family
may not be able to afford the food it needs,
ACT.md enables an integrated care team
with connections to the right non-medical
resources to arrange nutritional counseling
or access to healthy food. The platform helps
care providers navigate rapidly changing
reimbursement models and submit new non-
medical activities for payment when possible.
Empowering patients and
their families
Care coordination has traditionally been
something done to a patient, but ACT.md
enables shared care coordination with a
patient and their caregivers. We believe
patients need to work in partnership with
their care teams, who understand their needs,
limitations, and network of caregivers. This is
key to providing quality care that helps people
achieve their goals. On the ACT.md platform,
patients and their families are empowered to
act in their own best interests because they
have access to their data and care plans, and
can communicate directly with everyone on
their care team.
 PATIENTS HIEs PROVIDERS ACOs

Greater connection to Visibility into events Better communication Improved quality, a

their care team and and information and coordination stronger return on
ability to become an for every patient across the clinical investment, and
A technology-enabled approach active participant in and the ability to and non-clinical care better value in
to whole person care has their care plan coordinate with non- team to improve managed care
far-reaching benefits clinical end users patient outcomes for HCHN patients

Care happens in the community

Providers across the country are implementing new models of care for complex and high-
need patients. However, EHR systems are not designed to make them successful and digital
communication channels with entities outside the traditional healthcare ecosystem are weak or
nonexistent. ACT.md supports new approaches to care with a flexible technology platform that can
drive new and unique workflows that transition across post-acute care, long-term care, and home- and
community-based services. Our solution augments data in the EHR with information generated by
community members so all providers have a holistic view of their patients in real time.

Better care outcomes can have a lower price tag

Forward-looking providers are embracing whole person care to provide patients with effective, lasting
and life-changing care. These models of care also present the opportunity to lower costs and unlock
greater economic value. ACT.md’s health collaboration hub empowers organizations to achieve better
outcomes that bend the healthcare cost curve.

• Facilitate the management, certification

and reimbursement of new non-medical WHOLE PERSON CARE
activities such as support for unskilled home
SUPPORT NEW
assistance for homebound patients MODELS OF Capture and manage
CARE WITH SDOH to more
effectively treat
• Lower care costs by reducing readmissions, TECHNOLOGY upstream needs of
missed appointments and wasteful spending diverse populations

• Measure whole person care activities to

demonstrate which programs are effective COMPLETE CARE LONG-TERM SERVICES
COORDINATION AND SUPPORTS

• Rapidly experiment with and validate new Connect and create Coordinate non-medical
programs that leverage community-based accountability among and in-home services
all providers who that are key to well-being
networks to meet patients’ needs share care and independent living

Learn more by visiting www.act.md

1
https://www.slideshare.net/dchase/cc-future-ecosystem-v-09
2
Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA. 2012;307(14):1513–1516. doi:10.1001/jama.2012.362
3
Beaton, T. (2018, February). 80% of Payers Aim to Address Social Determinants of Health. Retrieved from https://healthpayerintelligence.com/news/80-of-payers-aim-to-
address-social-determinants-of-health.

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