Christiana Care Care Link
By participating in the Christiana Care Quality Partners ACO, providers benefit from the value of Christiana Care’s Care Link – a robust information technology-enabled network of care coordination support services that works with providers and patients to optimize outcomes.
Unlike traditional care coordination programs, Care Link harnesses an information technology platform that integrates all available sources of a person’s health data – including admission and emergency department visit information, physician visits, lab results, radiologic reports, pharmaceutical use and claims data. This information is integrated into care coordination software that supports Care Link’s interdisciplinary team in providing care coordination services to providers and their patients.
Care Link identifies the patients who are at highest risk and who have significant care needs. This includes identifying patients who do not regularly access primary care and preventive services. Understanding who is at risk for poor health enables clinicians to proactively reach out and connect individuals to the health services they need.
Care Link offers Providers:
- An interdisciplinary team that includes nurse care coordinators, social workers, pharmacists and support staff (under the direction of a Medical Director) who are available to address clinical, behavioral, social and other care needs that patients may have that is affecting their ability to achieve optimal health and wellness.
- An information technology system that captures and analyzes volumes of clinical and claims data to support clinical decision making, identify gaps in care and assist providers in achieving quality outcomes.
- Support in addressing barriers to patient’s seeking care by coordinating physician office visits, providing the transfer of information for seamless care transitions if patients require nursing home care, home health visits, other post-acute services and access to community based services.
- Educational support to assist providers in caring for those patients with chronic disease to self-monitor and achieve established goals of care.