Medical Transitional Care Patient Management System and Associated Business Method

摘要

The present invention pertains to novel medical post-discharge patient management system and associated business method that provides a means to track patients health after post-discharge using a program that employees a plurality of mathematical algorithms and software instructions for analyzing data that results in developing customized individual care plans that incorporate all of the unique co-morbidities of each patient. The system and software components includes an individual care plan (“ICP”) engine which receives data regarding the patient, their contact information and co-morbidities and uses the data to construct custom individualized care plans for each patient, based on their unique case mix of morbidities. The system software also includes IVR engine the works in conjunction with the ICP engine to contact patients using outbound interactive voice response, email and text messaging to ask the questions in the patients' CallPaths.

主权项

1. A method for collecting data during a medical transitional care period and generating an individualized care plan, the method comprising the computer-implemented steps of:
a) receiving patient data from a referral source such as a hospital or care system that includes all of the patient's disease states; b) evaluating all of the disease states for a specific patient and creating an individualized care plan for the specific patient through a set of validity rules; c) initiating action within a computer system based on the individualized care plan data to connect with the patient and correlate the data to a database, d) returning one or more message(s) to the patient, e) executing additional software instructions, and/or any combination of these actions; and; f) organizing the data in such a manner as to create trending charts or results records in the database that can be used to predict the need for interventions.