System and Method for Coordinating Care within the Health Industry

Abstract

The present disclosure is directed to a computerized method, system and software application for coordinating medical care through a Pathways Community Hub (HUB). A Pathways Community Hub is a network of care coordination agencies which focuses its mission towards reaching individuals within the community having the greatest risk-factors through the deployment of service providers such as community care coordinators. The Pathways Community Hub finds at-risk individuals in need of medical, health-related or social services, treats identified risk factors and measures a patient's risk status over time. The goal of the Pathways Community Hub is to achieve a reduction of risk among patients through open communication and collaboration among service providers including medical service providers and community-based organizations and to reduce the overall cost of medical, health-related and social services over time within a region.

What is claimed is: 
     
         1 . A system for coordinating medical care comprising:
 a hub computing device which operates as a hub portal comprising a processor, a display and a non-transitory computer-readable storage medium containing a set of instructions encoded thereon, the system comprising:
 a data collection system, wherein the data collection system provides a database of a plurality of clients including client information and referral information, a database of a plurality of medical, health and social service providers, and a database of community health records for a plurality of patients with various service providers through use of the system, wherein the data collection system allows for information to be received, recorded and accessed in the client database, the service provider database and the community health record database; 
 a measure, process and data display system wherein data related to a patient's community health record is run through artificial intelligence learning processes which analyzes the data and generates an output of recommendations for pathway referrals and/or treatments and which analyzes multiple patient data within a particular region and outputs data directed to health related trends within a particular region, wherein the measure, process and data display component further analyzes which pathways provide the most successful outcomes for individuals with certain conditions in a particular region, determines the factors that cause poor health outcomes within a community, determines which pathways are likely to provide the most successful outcomes for individuals having certain conditions in a particular region and provides pathway recommendations for individuals within a particular region; and, 
 a health bridge referral system, wherein the health bridge referral system allows the hub portal to receive a request for a referral from the client, patient and/or service provider, accesses a patient's account, conducts a search of service providers through a search engine, selects a service provider based on the output of recommendations for pathway referrals and/or treatments generated by artificial intelligence learning processes in the measure, process and data display system and inputs a response to the patient referral request in the hub portal. 
   
     
     
         2 . The system of  claim 1 , wherein the system is accessible by a plurality of client computing devices,
 wherein the client computing devices are capable of accessing and using a search engine system run on the system for identifying service providers, a messaging system run on the system for electronically communicating with service providers, a scheduling system run on the system for scheduling appointments with service providers and a confirmation system run on the system for confirmation of appointment requests and referrals,   wherein the hub computing device is directly linked to the client devices and communicatively coupled to the client devices through a network connection.   
     
     
         3 . The system of  claim 1  further comprising a first monitoring system, wherein the first monitoring system allows a hub portal operator to enter a patient's account information and community health record, access, retrieve and view information associated with the patient within the account, set up patient-provider referrals and monitor electronic communications between the patient and a service provider with respect to particular patient referrals. 
     
     
         4 . The system of  claim 1  further comprising a patient account status system which allows a hub operator to monitor the patient's status of treatment within a particular pathway or treatment and which allows the hub user the ability to close a patient's account upon completion of the patient's pathway or treatment and
 further comprising an archiving system which allows the hub operator the ability to move a particular referral or pathway or treatment to a historic tab upon completion of a patient's referral, pathway or treatment. 
 
     
     
         5 . The system of  claim 1 , further comprising an appointment feedback system which provides notice to a third party referring the patient for an appointment with a service provider that the appointment was kept. 
     
     
         6 . The system of  claim 1 , further comprising a health record integration system which allows a patient's medical records or electronic health record with a medical service provider to be uploaded and merged with the patient's community health record established with various service providers through use of the system. 
     
     
         7 . The system of  claim 2 , wherein the messaging system allows for multi-user, real-time communications between the patient and the service provider. 
     
     
         8 . The system of  claim 3 , further comprising a second monitoring system which allows health care providers to monitor electronic communications between the patient and community service providers within the system. 
     
     
         9 . The system of  claim 2 , further comprising a direct messaging system which allows patients to communicate with service providers confidentially in a secure environment within the system. 
     
     
         10 . The system of  claim 1 , further comprising a tracking system wherein community health records are entered into a patient's account within the system through completed Pathway forms which track the outcomes performed by the service provider. 
     
     
         11 . The system of  claim 4 , wherein the archiving system allows for recording and storing of patient community health records related to service visits, general patient records and general data entry related to the specific services provided. 
     
     
         12 . The system of  claim 11 , further comprising an auto-invoicing system, wherein the auto-invoicing system works in conjunction with the archiving system to automatically generate bills for services provided to the patient. 
     
     
         13 . The system of  claim 12 , wherein the auto-invoicing system is performance based in that it takes into account a patient's successful completion of pathways with the service provider in generating bills. 
     
     
         14 . The system of  claim 1 , further comprising a referral resource ranking system wherein the hub user and service providers are provided a curated list of referral resources that are ranked according to performance and curated and maintained by HUB operations. 
     
     
         15 . The system of  claim 1 , wherein a specific standardized pathway is identified and assigned to the patient for each risk factor identified by the service provider. 
     
     
         16 . The system of  claim 15 , wherein a reduction in risk is recorded and tracked by the completion of pathways. 
     
     
         17 . The system of  claim 16 , wherein in the event that a pathway is not completed or a desired outcome is not reached for a given patient, the pathway is closed by marking it “finished incomplete”, and wherein the service provider documents the reasons why the pathway was not successfully completed and records this data within the patient account within the system. 
     
     
         18 . The system of  claim 17 , wherein pathway incompletion data is monitored and tracked by the hub computing device and wherein the hub computing device compiles a list of reasons why pathways are “finished incomplete”. 
     
     
         19 . The system of  claim 18 , wherein the hub computing device conducts a community needs assessment based on information retrieved from pathway completion. 
     
     
         20 . The system of  claim 1 , wherein a hub operator uses the system to generate agreements with community-based organizations or agencies to delineate expectations around hiring, training and supervision of service providers employed with such community-based organizations or agencies. 
     
     
         21 . The system of  claim 1 , wherein the hub user, service provider, and community-based organization or agency designates specific learning modules or training videos for the patient to view within the system. 
     
     
         22 . The system of  claim 1 , wherein patient engagement is tracked within the system and notifications concerning the patient's engagement is transmitted to all financial stakeholders.