Our CHI endeavors to form a coalition that fosters single source collaboration between Community Based Organizations (CBO's) currently providing services that improve health, with local healthcare providers and social support networks
PARTICIPATE
Participate with a leadership role in the local healthcare community.
CREATE
Create a referral network for programming and allow for expansion of services delivered to the community.
INCREASE
Increase member revenue for health and wellness services including from Medicare and other Payers.
COLLECT
Collect patient data in a HIPAA compliant EHR to allow the Patient’s Care Team to access necessary data for reporting outcomes in addition to filing medical claims.
“Community Integrated Health aims to intentionally strengthen the relationships between traditional healthcare systems and Community-Based Organizations (CBO’s) in order to help all community members live their healthiest lives”
- NC alliance of medical partnership summit 9/6/17
OurCHI FEATURES
DIGITAL REFERRAL
Imports data from Primary Care Providers (PCP) allowing for pushing patient data to the Our CHI EHR platform.
PROGRAM MANGEMENT
Purpose built EHR Custom User Interface (UI) enabling creation of programs, schedules, patient enrollment, coach assignments, and outcomes reporting.
PATIENT ASSESSMENT
“Coaches” leverage the Our CHI mobile application for patient data entry, outcome trending and reporting.
PATIENT DATA TRANSFER TO PCP
Digital transfer of PCP critical MIPS/MACRA data directly from Platform EHR CCDA interface.
CLAIM SUBMISSION TO MEDICARE/PAYERS
Integrated billing software with certified medical billing staff will scrub and submit medical claims for payment.
1. Primary Care Provider
Primary Care Provider
- Refers patients with chronic conditions to CBO
- Referral is digital and directed to specific CBO program
- Receives patient updates of vitals and level of paricipation
- Determines on-going patient care plan based of CBO outcomes
2. Local CBO
LOCAL CBO
- O-CHI application used to create & manage programs
- Mobile app allows for patient assessments
- Patient information stored in HIPAA compliant clinical database
- Backend billing functionality offers claims submission
- Collected data available for O-CHI reporting functionality
3. UNITE US Platform
- Provides solution to digitally move patient data bi-directionally
- Offers cloud based network to services supporting SDOH
4. CBO Trainer
CBO Trainer
- Sees only participants information and programs they are assigned
- Uses handheld tablets to perform attendance & assesses participation performance
- Collects participants vitals and quantitative results
CBO's Offer Evidence Based Programs for Physician Referred Patients
Evidence based programs will improve overall health such as the ones below offered by YMCA's:
Diabetes Prevention Program
Livestrong
Healthy Weight and Your Child
Blood Pressure Self-Monitoring Program
Moving for Better Balance
Weight Loss Program
Enhanced Fitness Program
For more information please contact:
Franklin Walker, MBA
(919)-833-3836
Email: fwalker@ncmedsoc.org
