As providers increasingly bear risk across the care continuum and more reimbursement is tied to outcomes, it has never been more important to ensure well-coordinated follow-up care. Yet managing this beyond the four walls of your clinical setting is challenging, requiring the coordination of patients, physicians, rehab specialists, home health workers, and many other disciplines.
Lumeon’s Care Pathway Management (CPM) platform is designed to help you connect everyone into a planned, risk-stratified pathway. Each patient is progressed through a premeditated plan of post-acute care, dynamically tailored around their individual needs.
Lumeon takes away a lot of manual back and forth by assessing patients early on and assisting the care team to set an optimized course of action for each individual. It then automatically progresses them through milestones such as coaching, appointments, risk screening and outcome monitoring.
The CPM platform allows you to use clinical protocols to determine the optimal series of post-acute activities for each patient. This pathway is then presented back to care teams who can see what tasks everyone (including the patient) has to complete and by when.
Your pathways can balance the use of automated and manual patient engagement techniques, based on risk factors and ongoing patient recovery scores.
A few features:
Integrate data from wearables/apps
Integrate and process data from wearables, apps or remote monitoring devices into your pathway. Monitor and escalate if data exceeds thresholds. Modify the patient pathway and activate different operational/engagement activities or transfer the patient into recall sequences based on this.
Adapt pathways according to risk
Lumeon can assign patients to different pathways based on your risk stratification protocols. This means it can maintain low-risk patients with more automated content, whereas high-risk patients have a higher frequency of nurse-led calls.
Patient goal tracking
Set and collaboratively monitor incremental progress towards short-term goals, (e.g. making a cup of coffee unassisted) using e-forms and automated coaching content. Build a tailored program based on the patient’s personal long-term goal (e.g. playing golf again).