Personalized care delivery and interventions with Dynamics 365
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Personalized care delivery and interventions with Dynamics 365

In this demo of Dynamics 365
powered by the healthcare accelerator, we’ll see a community
clinical care team provide personalized services for a new patient. As a care coach I’m
provided a unique que of recently discharged members or referred
members. As I jump into the members record. I’m greeted with
relevant alerts that let me know what’s going on with the member
as well as any clinical information such as medications,
conditions, or even appointments, and as I scroll to the left the
built in artificial intelligence of the system can analyze
sentiment and serve it up to me in actionable cards. Reviewing discharge summaries
has never been easier. I’ve got access to that via the documents tab. And when I call or visit
with the member I can easily track all my notes and
interactions in one place with just a click with my mouse and
what’s great is once that saved my entire care team can see the
history of that interaction. As I talked to the member about
various care management programs. I can capture their
consent as well as the total number of coaching days that are
allotted for that plan, and if I need to schedule out any team
resources. I’ve got access across all their calendars and
can simply set that appointment. Walking the member through
clinical assessments, powered by guidelines such as MCG is never
been easier. As I open up the assessments. A lot of the
information is automatically filled in based on the member
record as well as previous assessments, and in real time I
can capture information that is updated wether I’m online or
offline and as I answer questions the assessments are dynamic. Once completed the
draft care plan is created with the appropriate problems, goals,
as well as interventions. As I review with the member I have
the ability to capture their consent and agreement. With the tools ability to
support IOT and connected devices patient monitoring is
easier than ever before. This gives me as the care manager
the ability to identify issues that might normally go unseen
for instance, as I look through the glucose readings. I can see
a spike in blood sugar levels around the same time, each
night. Which of course prompts me to contact the member and
talk about what might be causing that. While on the phone I have
the ability to pull up the existing care plan in some of the corresponding goals and
through the discussion identify that the member is consuming ice
cream before they go to bed. So I can create a new intervention
and recommend sugar free jello. Now that the intervention’s
updated I can also add associated barriers, in this
case the patient’s husband is purchasing a lot of the ice
cream every night, but now we’ve got a plan in place. Let’s now
look at how behavioral social worker on my team can also
support Nikisha from the same member record, I can click into
services to see what’s eligible for this member and from a
simple dropdown choose the relevant services I want. When
the service is open I can go through a step by step process
to request that service from the vendor, but also have the
ability to integrate into their website and kick off requests
and services right from there. Even if it’s not a paid for
service, I have a way to help the member in a way that’s right
for them. Let’s now jump back in from the perspective of our care
coach to see how we can graduate. This member from our
care management program as I continue to look at the glucose
readings I can now see that they are within normal range, and the associated risk scores
also lower. At this point I can call the
member, discuss their improvements and get their
consent to graduate them from the care management
program. Dynamics 365 empowers the entire clinical care
team to improve the health of both members and
surrounding communities.

About Bill McCormick

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