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Care Coordination Tool

Tennessee has developed a shared Care Coordination Tool that allows providers participating in the Patient Centered Medical Home (PCMH) and Tennessee Health Link programs to be more successful in the state’s new payment models. This tool was built and implemented in partnership with Altruista Health.

The tool identifies and tracks the closure of gaps in care linked to quality measures. It also allows providers to view their member panel and members’ risk scores, which facilitates provider outreach to members with a higher likelihood of adverse health events. The tool enables users to see when one of their attributed members has had an admission, discharge, or transfer (ADT) from a hospital or emergency room and track follow-up actions. TennCare is actively working to provide statewide ADT information through the Care Coordination Tool.  As of March 2018, 63% of hospitals and 70% of licensed hospital beds statewide are providing ADT feeds in the Care Coordination Tool.  Through strong partnerships with THA, etHIN, and CHS, the State anticipates at or near 100% statewide coverage by the end of year 2018. Furthermore, the tool provides claims-based medication information about members for providers to view.

The Care Coordination Tool was piloted with nine organizations from across Tennessee in the summer of 2016. Based on feedback from providers, additional enhancements and customization were made to the tool prior to launch, and additional enhancements are scheduled for future releases on an ongoing basis.

The Care Coordination Tool was rolled out to PCMH and Tennessee Health Link providers in February 2017. The tool will be made available to additional Tennessee providers who are participating for the first time in the State’s PCMH and Tennessee Health Link programs in 2018. In the future, the State plans to expand access to the Care Coordination Tool to any primary care providers who wish to participate.