A digitally orchestrated chronic disease management program
Chronic medical conditions account for more than 75% of healthcare spending in the US [1]. Not only is it difficult to create an integrated plan of action for each patient, but ongoing monitoring of patients is costly and operationally challenging.
Lumeon’s Care Pathway Management (CPM) platform enables hospitals, health systems and PCPs to lower the costs associated with managing patients with one or more chronic conditions, by creating a centrally coordinated integrated plan of care, with automated digital touchpoints.
This means patients can be automatically recalled for regular check-ups and screening and all care professionals can see changes in risk status and how close patients are to achieving their personal goals. In-between visits, patients can also be virtually monitored at home, with escalation based on data collated from e-questionnaires or remote diagnostic kits.
Unite care teams and patients using a personalized plan of care
Providers can use the Lumeon CPM platform to create a shared longitudinal care plan, showing the ideal checkpoints for each patient. Lumeon then actions this, allocating or automating tasks and updating the plan in real-time based on its interactions with patients, care teams and existing technology (including EHRs).
A few features:
Real-time view of shared care pathway (recall, screening data, outcome tracking, checklists, care team tasking, timers etc.)
Ability to extend the plan across multiple care teams/specialists/settings as required
Auto-escalation of patients based on data from remote monitoring devices/e-questionnaires
Set and track personal goals for patients within or across settings
Video consultations
A few possibilities
Adapt pathways according to risk
Auto-escalate patients if data they share regularly breaches their risk band, or if they start to disengage with digital activities. Maintain low-risk patients using automation and divert resource onto high-risk patients via higher frequency phone/video engagement or patient recall.
Personal goal tracking
Set and track personal goals for patients to help them manage chronic conditions. For example, help COPD sufferers to stop smoking or manage anxiety. Create digital coaching programs that enable care teams to collaboratively focus on individual patient needs.
Integrate wearables/remote diagnostics
Integrate data from remote monitoring devices such as blood glucose monitors or cholesterol checkers etc. and trigger automated escalation sequences if data goes out of threshold.
