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Problem Tech Solves
Tech Brief
Seniors and other adults with unmet social and health needs are often overlooked by the traditional health care system. When it comes to this population, one needs to address not just their medical challenges, but also a range of issues – from food security to housing to loneliness – that affect their health. This requires the right team of professionals, supported with the latest technology, and operating in a system in which they are paid to keep patients healthy. Patient3D® enables ConcertoCare’s care teams to identify opportunities, or sources of value, to improve care delivery and social support, based on a patient’s history. This benefits the patient by improving their care experience and quality, and reducing costs. Patient3D® encompasses social determinants of health for each patient, and conducts a risk assessment. From there, Patient3D® tracks gap closures in real time to aid with progress tracking and reporting for both the social and medical needs, so that our care teams can deliver the most appropriate care to each patient at the right time. Patient3D®’s proprietary analytics capabilities inform our care teams’ decision-making, whether it’s addressing a sub-optimal medication combination that could exacerbate a medical issue, or preventing a patient from a trip to the emergency room for something that can be addressed at home.
Tech Differentiators
ConcertoCare gives seniors care where they want it most. Keeping seniors and other adults out of the hospital and in the comfort of their homes is what nearly nine out of ten seniors want – and happens to be better for them, their health, and the health care system. ConcertoCare addresses the whole patient Many at-home care providers focus only on the medical needs of our most vulnerable populations. To care for the sickest seniors, one needs to address not just their medical challenges, but also a range of issues – from food security to housing to loneliness – that affect their health. By providing at-home care, ConcertoCare can serve those who do not have access to transportation, ensure their home environment is safe, determine if they are receiving adequate nutrition, and help minimize potential future risks. ConcertoCare represents the population it serves ConcertoCare is one of the very few companies that focuses on caring for lower-income, minority communities in the comfort of their homes. ConcertoCare serves many dual eligibles, and also runs PACE programs – a Medicaid benefit that enables seniors to receive nursing home-level care at home. ConcertoCare deploys physician-led interdisciplinary teams who reflect the diverse population ConcertoCare serves and can address a wide range of health and social needs. ConcertoCare intentionally hires care teams that have cultural parallels to the individuals they care for. They not only understand the culture and needs of the population but the resources, geographies, and accessibility of the community.
Validation
ConcertoCare conducted separate studies of its CarePartners program – an at-home wrap-around primary care program that partners with patients’ primary care provider (PCP) – and its Geriatric Primary Care program – an at-home primary care model where ConcertoCare serves as the PCP of record. For the studies, ConcertoCare performed a comparison analysis between ConcertoCare patients and non-ConcertoCare patients in a state where its CarePartners and Geriatric Primary Care programs are deployed. For CarePartners, the total study population was all Frail and Vulnerable (FAV) members in the health plan’s MA and Duals population. The treatment group was the set of FAV members ConcertoCare’s field team successfully engaged in the CarePartners program; the control group was all non-engaged FAV members during the same period. For Geriatric Primary Care, the treatment group consisted of MA and Duals members aligned to a ConcertoCare PCP, while the control group consisted of all other MA and Duals members in the health plan’s book. Results from the studies are below: Compared to health plans, ConcertoCare identified meaningful improvements across CarePartners inpatient utilization (admits and readmits), as well as ER visits: 38 percent admission, 25 percent ER visit, and 20 percent readmission difference. ConcertoCare identified meaningful improvements across inpatient utilization, ER visits, and costs among its Geriatric Primary Care patients in comparison to health plans across a ten month period in 2020: 69 less acute admits, $217 in costs savings, and 27 less ER visits.
