When MMR Healthcare started using Transition Care Management from eClinicalWorks, they learned the chronic heart failure, falls, and influenza were the leading causes for hospital readmissions among their patients. With unified dashboards to keep all providers informed about each case, they have improved compliance with follow-up appointments, helped patients with their medications, improved patient education around diet and lifestyles, and reduced their hospital readmission rate down to 10-12%, well below the national average of 18%.

For Dr. Martha R. Rodriguez, Hierarchical Condition Category (HCC) coding is really a language of its own, and one that today’s practices must learn in order to effectively deliver quality care and manage their budgets. The HCC module from eClinicalWorks has helped her practice more accurately risk-stratify patients, leading to better care. Providers at MMR Healthcare are thinking differently than before, and speaking a common healthcare language — with dramatically improved results.

While MMR Healthcare had always provided chronic care, in 2014 they begun using the CCM module from eClinicalWorks. They partnered with a local pharmacy college, increased contact with vulnerable patients in-between visits, and avoided unnecessary hospitalizations and readmissions. While few patients with chronic illnesses are cured of them, the CCM program has helped educate patients, keep them in closer touch with the practice, and improved their quality of life.

Dr. Martha R. Rodriguez used to have data nightmares every time her practice was inundated with lists from insurers showing gaps in patient care. Since using the HEDIS module and dashboard from eClinicalWorks, her practice now has templates that can work with real-time data to proactively close those gaps in care. Plus, knowing which patients need which tests allows them to easily create Messenger campaigns for more effective patient outreach.