Transitional Care Management (TCM) Platform Development for a US-based Healthcare Provider - Elite Care

Locomo’s in-built testing automation framework helped to identify and resolve issues early on, ensuring the platform’s reliability and performance. This structured approach enabled the team to focus on specific functionalities within each Release Unit, facilitating timely adjustments and improvements before deployment, so they do not disrupt the overall effectiveness of TCM delivery.

As a result, the final platform was a robust, reliable, and high-performing solution that effectively transformed transitional care delivery. It empowered healthcare providers with intuitive tools for managing patient information and coordinating care, ultimately improving patient outcomes.

Our development focused on several key aspects, including:

A critical component behind the platform’s working was its integration with Redox, a middleware solution facilitating seamless data exchange among various Electronic Health Records (EHR) systems.

Locomo enabled seamless integration of Redox with the TCM platform. This was done to pull comprehensive patient data from EHRs (such as AdvancedMD). To ensure that the information stays relevant, this data is being pulled every 7 days post-patient creation and at the time of discharge; enabling accurate medication reconciliation and patient management.

With access to such vital data – including admissions, discharges, transition details between inpatient facilities, medication summaries, diagnoses, and other key care events – practice admins were able to make timely, informed decisions based on the most accurate patient information. Additionally, they could also update details on the platform regarding patient visits, summary notes, etc.

In order to develop a HIPAA-compliant application, Team Daffodil implemented encryption for patient data both at rest and in transit to prevent any unauthorized access. Team Daffodil established role-based access controls to restrict data access to authorized personnel only. Two-factor authentication was leveraged to safeguard against any unauthorized access. Periodic security audits were also conducted to maintain compliance and address potential vulnerabilities.

Team Daffodil leveraged Locomo to develop the Facility Admin and Practice Admin portals, essential for effective care coordination. Its modular design facilitated rapid feature development, while the in-built deployment automation enabled swift & error-free deployment.

Key features of the portals were:

Dashboard: A central hub providing real-time updates and a comprehensive view of patient details and care tasks. This feature allows users to monitor patient transitions and manage care efficiently. Dashboard stats show TCM completion in the last 30 days. An ‘Encounter’ is considered ‘TCM complete’ if its tasks are done within 14 days, otherwise, the encounter is marked as a ‘TCM miss’ on the dashboard to help identify the reason and resolve it in the future.

Facilities: Showcases various healthcare facilities to streamline patient data management and ensure smooth transitions between different care settings.

Chat: An internal communication tool for real-time collaboration among care team members, enhancing coordination and ensuring effective management of patient care.

Tasks: Manages and tracks transitional care tasks such as medication reconciliation, visit scheduling, and patient follow-ups. This feature automates task management and ensures that all required actions are completed within specified timeframes.

Admin: Provides tools for managing user roles, access controls, and system settings. This feature supports platform customization and ensures adherence to care management protocols.

Patient Chats: A secure messaging feature enabling direct communication for specific patients by their care teams. This enables follow-up discussions and ongoing support.

Alerts: The system provides real-time alerts for different roles to make things happen in a time-bound manner. For instance, the care team is notified when there is an outstanding task due in the next 24 hours.

TCM note: Once TCM is completed for a patient, the option to generate and download a TCM note in a PDF format is made available on the platform. TCM note is a summary of all the TCM tasks along with related details of the tasks that were done post-patient discharge.