As the costs of providing care for high-risk Medicaid beneficiaries sky rocket, states, counties, and community provider coalitions are looking for ways to support healthier communities while also reducing costs. The social determinants of health are critical to improving outcomes and reducing care costs. A Medicaid care delivery model that is gaining popularity involves connecting primary care, behavioral health, and social service providers (e.g. Homeless Management (HMIS), workforce services, intellectual and developmental disabilities) in order to deliver whole-person care coordination.

Community Health Partnership (CHP) is a member-based coalition that manages the care for over 180,000 members in Central Colorado. Eccovia Solutions has partnered with CHP to create a community health data-sharing infrastructure. Two key results from this model include lower emergency department visits, and hospital readmissions for adult patients.

Eccovia Solutions has over 20 years of experience helping organizations track, manage, and report on care for high-need individuals. Our ClientTrack Care Coordination platform is a truly integrated and patient-focused system that connects providers across the community with powerful tools, including:

  • Coordinated screenings for medical health, mental health, behavioral health, and health-related social needs
  • Real-time communication, care coordination, and data sharing across organizations
  • Single point of entry assessment and referral for services
  • Comprehensive Care Planning
  • Referral Management
  • Care Team Management
  • Prioritization and Risk Stratification
  • Federal & State compliance reporting
  • Engagement Portal (Provider & Patient)
  • Population Health/Advanced Analytics
  • Ability to push and pull a variety of data types
  • Quality Measures and Reporting
  • Native Mobile Accessibility

Whether you are looking track, manage, and report on individuals in your Medicaid ACO, or to be part of a Medicaid waiver data-sharing infrastructure, we can help.