Care Coordination Tool

Immediate access to more reliable and timely quality measures. The CCT calculates and displays all of the state approved PCMH and THL HEDIS Quality Measures, including diabetes screening, well-child visits, childhood immunizations, and high blood pressure monitoring.

Ability to view the count of members with care gaps open, and the total number of members that are up-to-date on care milestones. This helps those needing care coordination based on care gaps and missed services identified from the PCMH and THL HEDIS quality measures.

Member panel information such as name, address, phone numbers, and more support outreach efforts as providers seek to connect with new and established members.

Admission, discharge, or transfer (ADT) data from hospitals and/or emergency rooms.

• List of Hospitals Submitting ADT Data

Immunization data reported by immunizing providers to the Tennessee Department of Health (TDH) for members under the age of 2 years, or aged 9-13 years.

Claims-based clinical data that outfits providers with information like risk score, medication history, diagnosis history, and visits—information that in tandem with knowledge regarding a member’s open gaps in care enables providers to establish a more robust understanding of a member’s overall medical history.

• Real time updates on drug contraindications, drug disease interactions, and drug allergy reactions
• Easy searching and segmenting of MTM members through a range of filters including chronic conditions, PCP, and zip code. As an added feature, alerts can be set for members with chronic disease, comorbidities and high-risk levels.
• Intuitive CMR/TMR that guides you through collecting patient information, assessing prescriptions, developing a list of medication-related problems, and creating a medication action plan.

Care alerts that provide information on new and enrolled members, particularly high-risk members.