The people behind Community Care — and how we are improving health services in our state
A community-based infrastructure to target patients and populations in need
The processes and measurements behind our outcomes
Programs to anticipate and address specific patient needs
New demonstrations, pilots and programs
Management ToolsPatient Management Tools
Patient Management Tools
Materials to support providers and help educate patients
IC Reports Center
Data drives targeted interventionsIC Reports Log-in (authorized users)
IC Report Site
The Informatics Center Reports Site
The Informatic Center (IC) Reports Site allows efficient and secure distribution of reports through a secured web-based report access and management application, with report access permissions determined by the appropriate scope of access of individual users. Network-level administrators authorize their own employees and providers by customizing their scope of access by practice or region.
Informatics Center Analytics and Reporting services serve a variety of functions:
Population Needs Assessment: Identification of demographic, cost, utilization, and disease prevalence patterns by service area. CCNC Networks can readily obtain information about the demographic characteristics, prevalence of chronic medical and mental health conditions, spending by category of service, and rates of hospital, ED, and other service use within their service areas. This aids in program planning and resource allocation; identification of outlier patterns (such as unusually high rates of personal care services); and tracking of local utilization patterns over time.
Risk Stratification and Identification of High-Need Patients. The size and complexity of the Medicaid population, in terms of physical health, mental health, and socioeconomic needs, necessitates intelligent mechanisms for identifying patients most appropriate for care management interventions, particularly in the face of limited resources. The use of historical claims data to screen patients for care management intervention can greatly improve the efficiency the care team. For example, we are able to flag patients who meet specified criteria for further screening by a care manager, according to patterns of service use over the prior 12 months (such as multiple ED and inpatient visits, multiple medications, lack of PCP contact, target medical conditions, and high cost). Similar reports are generated for specific initiatives or pilot programs (for example: identification of patients with newly diagnosed asthma, heart failure, and diabetes; or identification of patients with poor adherence to their blood pressure medications for a telephonic health coaching intervention).
Monitoring of ED and Inpatient Visits. A number of utilization reports are generated automatically from the IC data warehouse, updating with every claims payment cycle, or from real-time data feeds from participating hospitals. These reports are very flexible for answering a variety of questions (e.g.: Are patients from my clinic having a high number of non-emergent ED visits during regular office hours? How many heart failure discharges were readmitted within 30 days, and did they bounce back to the same facility or a different location?); and for identifying impactible patients in a timely fashion (e.g., quick identification of hospitalized patients who may need care management support for successful transition after discharge).
Tracking of Care Quality and Performance Indicators. Using annual chart review and quarterly claims review, CCNC tracks quality measures related to diabetes, asthma, heart failure, cardiovascular disease, pediatric well visits and dental care, and adult breast, cervical, and colorectal cancer screening. Measures can be aggregated to the practice, county, network, or statewide level. Results can be viewed in spreadsheet format for easy comparative view across practices, or as a comprehensive practice-level, county-level, network-level, or program-level report with trend information. The IC Reports Site also enables program performance tracking for monthly reporting to the state Medicaid agency and state legislature. Tracking of key process, outcome, cost, and utilization metrics provides stakeholders with assurance that efforts are aligned toward the overarching goals of cost savings and quality improvement.