Health Care Homes
Health Care Homes is one of the largest innovations in healthcare reform in Australia. This new model of care targets the millions of Australians with chronic and complex conditions, aiming to keep them out of hospital, and living happier and healthier lives at home.
The cdmNet platform provides a range of cloud and mobile services to seamlessly support every component of the Health Care Home.
Risk Stratification
To deliver this new model of care, it is essential to identify patients at risk and and identify their level of need. Precedence’s PracticeProfiler provides the government-mandated Risk Stratification Tool for use by all GP practices participating in the Health Care Homes initiative.
Uses an Australian-validated Predictive Risk Model to identify patients at risk of hospitalisation based on disease profile and other medical data.
Generates alerts at the point of care for high risk patients, making it easier to incorporate the Health Care Home and other models of patient-centred care into traditional health practice.
Automatically generates smart-form questionnaires, pre-filled with clinical and other data from the practice, to determine patient needs and level of risk.
Guides the GP or practice nurse through the entire enrolment process, including identification, needs assessment, and risk determination, to certificate generation and final program enrolment.
Shared Digital Care Plans
Precedence’s cdmNet coordinated care platform and shared care planning services have been extended to include all the features required for the Health Care Home.
Encompasses all Health Care Home workflows to guide the user through the care planning, tracking and review processes.
Produces evidence-based, multi-morbidity digital care plans automatically personalised to the patient.
Seamlessly shares the patient’s GP medical record, digital care plan, progress notes and My Health Record with the care team.
Tracks actions against the care plan and triggers care plan reviews at the correct time based on patient’s risk tier.
Automatically generates and electronically distributes key documents, such as allied health referral forms, so providers can spend more time with patients and less on paperwork.
Alerts and notifies the care team of care plan activities and events so no one falls between the cracks.