As part of a Maine DHHS Analytics Pilot Project, DFD Russel Medical Centers care managers have been using the HealthInfoNet Analytics and Reporting Platform to identify patients at risk for Transitions of Care Management.

The team broadened the use of HARP to risk stratify patients for Emergency Department (ED) and Hospitalization risk, Polypharmacy Risk and for Chronic Care Management.  The team plans to employ the Population Management workflows for Population Health and Quality Measurement later in 2018.

The Use Case Report highlights workflows, documentation, adoption, and outcomes.