Digitally orchestrated outcome tracking

Whether it’s monitoring chronic conditions, rehabilitation after surgery, or the effectiveness of specialist treatment, outcome tracking is essential to avoid readmission penalties and to comply with value-based payment models.

Tasking care operators to make phonecalls, or asking patients to come back into the care setting can be manually intensive and ineffective.

Lumeon’s digital outcome tracking solution enables providers to monitor patients remotely, supporting care team engagement with sophisticated automation. Periodic patient e-questionnaires and risk scoring can trigger protocols that fast track low-risk patients with minimal intervention, and direct more human resource at medium and high-risk patients. This means care team time is focused much more effectively.

Patients benefit from being able to track their progress via integration with your patient portal and are nudged to report back at convenient times, using familiar channels. Providers benefit by being able to monitor patients with greater regularity and in increased volume.

Key benefits:

Reduce readmission risk
Adjust treatment/medication plans
Improve patient experience and outcomes
Perfect bridge into broader pathway solution

Key features

Lumeon enables you to track progress towards outcomes that matter to patients, so you can alter treatment courses or escalate patients to care teams before their condition worsens.

A few key features:

Customizable e-questionnaires to track PROs (patient recorded outcomes)
Automated escalation if results go out of threshold
Ability to maintain patients on risk-stratified pathways
Result graphing
Personal goal tracking
Integrate data from apps/wearables/telehealth
Integrates with your EHR/pathology/patient portal etc.

Use case

Post-acute orthopaedic care

After a patient is discharged from knee surgery, the Lumeon CPM platform prompts their care navigator to conduct a phonecall 24 hours later and run through a checklist. The patient is categorized as ‘low-risk’ so is sent a series of daily e-questionnaires, activities and reminders. They are asked to input their KOOS scores which track specific functional goals, such as whether they can get out of bed unassisted.

If the patient reports unexpected data, such as a high temperature or inability to complete a goal, they can be escalated into a call list. Similarly, if forms go uncompleted, Lumeon can prompt a nominated friend and family supporter and then escalate to care teams if a response still hasn’t been generated.

Lumeon automatically graphs results and providers can see progress day by day, week by week.