KENNETH SILVERSTEIN, MD, Chief Clinical Officer, Christiana Care Health System (Wilmington)
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“There has been an increase in chronic disease in complex patients. We know that there’s a very small percent of patients that drive a large percentage of the spend in healthcare. There’s a cost to the community. The bigger picture is on the patients with multiple comorbidities and who have their own economic burden to bear — productivity in society is down and their quality of life weighs down on them. We have our share of patients in the community who carry this burden of chronic disease, and that’s our most pressing health concern.
We’ve created Care Link, an interdisciplinary care coordination team. We have nurses, case managers, social managers, pharmacies, support staff, medical directors and physicians as well, and we provide support to physician practices. We’re using innovative software to track our most complex patients and predictive analytics to see who’s going to need attention, when and where. We’re incorporating data from Delaware Health Information Network, using data from claims and EHRs, then using predictive analytics to develop risk profiles for these patients to determine a work plan for care coordinators to be able to take better care of patients.”
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