AveCare System

Avedon’s AveCare software system provides a seamless integration of the following care management functions:

• Utilization management
• Case management
• Disease management and education

Because the system is patient-centric, all information relevant to a particular patient is accessible from all system modules.  With a patient selected, the user can access/view:

• All patient demographics, including contact information, eligibility, preferred language, enrollment in case management and/or disease management, community referral information, and much more,
• All contacts made with or on behalf of the patient for all care management functions,
• All notes entered relative to the patient for all care management functions,
• All of the patient’s claims data (if provided)
• All utilization review, case management and disease management activity on behalf of the patient, including inpatient/outpatient reviews, health risk assessments, disease-specific assessments, educational sessions and care plans.

In addition, a centralized queue function allows for the management of a patient among the various care management functions, so that a patient may move seamlessly from a utilization review activity/function to a case management activity to a disease management activity and back, with all actions recorded by the system. Moreover, in the utilization review function, the system automatically alerts a user if the patient is enrolled in case management or disease management, has been assigned a case manager or disease manager, and/or has pending activity (e.g., follow-up tasks) associated with other functions. Therefore, patients can be assigned to individual users such as a specific case manager, yet be accessible to other users as necessary and as dictated by internal policy.

The AveCare system supports the automated identification and referral of candidates for case management, disease management, maternity management or quality management. Candidates are automatically identified either through the utilization review process or through the filtering of claims data, if available. In the utilization review process, the entry of a condition, diagnosis and/or procedure automatically goes against a list of diagnostic and procedure code triggers, along with utilization algorithms (such as multiple hospital stays within a given period) and alerts the reviewer for specific referral to a specialty program,

In the loading/filtering of claims data a similar list of triggers is applied to identify program candidates, who are then placed in a “group” queue (by disease for disease management, or into a case management or quality management queue) for nurse review.

Case Management

The Case Management module is designed to address members with on-going care needs using the online “fill-in-the-blanks” Health Risk Assessment and Disease Specific Assessment tools to determine the patient’s care needs, along with automated care plan. 

Disease Management

The Disease Management module uses claims data analysis to identify members who will benefit from education and management of their chronic diseases.  The module provides a step by step best practices approach to managing and educating members with the following diseases:

• Asthma
• Diabetes
• Chronic Obstructive Pulmonary Disease
• Coronary Artery Disease
• Congestive Heart Failure
• Hypertension

System Rules

The AveCare system offers the flexibility to designate general or client-specific work rules governing actions of the system.  Rules can be set for functions such as assigning precertification, case management and disease management cases; tracking compliance timeframes; and rendering automatic precertification approvals/denials based on benefit provisions.  Examples of the flexibility within the functions are as follows:

• Assigning cases
• Assign manually from list
• Assign to a designated queue from which users select item
• Assign based on a designated rotation of nurses
• Assign to user with fewest queue items
• Assign based on diagnosis or procedure  (overrides other designations)
• Tracking compliance timeframes
• Track and notify timeframes for initial screening, completion of Health Risk Assessments, Care Plans, etc.
• Track and notify timeframes for completion of precertification reviews
• Track and notify timeframes for completion of discharge info
• Rendering automatic precertification approvals/denials
• Automatically approve based on “no authorization required”
• Automatically deny based on “no benefits provided”
• Automatically approve/deny based on procedures per day, week, year, lifetime and rolling period of time

In addition, non-rule functions can be activated to track user-specific activity, to assign users to specific work groups and limit access to users/clients within that work group, to provide automatic supervisory notification of overdue items, etc.

Letters

Within the AveCare system, letters are highly customizable according to client needs, including the capability for entering user variables at the time of letter generation.  Once letters are generated, they can be previewed/edited before forwarding for printing.

Stop-Loss Carriers

AveCare also supports interaction with stop-loss carriers through the automated application of the carriers’ trigger lists for the identification of high-cost, high-risk members. The triggers are applied at the time of utilization review (creating a “large claim alert” for the UR nurse) and at the loading of claims data so that the applicable members can be identified as high-risk, high-cost patients and the carriers can be alerted. Reports can be generated from the system indicating those patients that have been identified in order to ensure that notification is forwarded to the carriers.

Provider Networks

The AveCare system facilitates the administration of provider networks through its Physician and Facility modules. When provider data is loaded, network participation is also loaded into the system, including multiple networks per provider and participation date spans. The modules also include other supportive information such as Tax ID, degree type, primary and secondary specialties, available languages, and CLIA number. During the utilization review process, the system will indicate whether the requesting facility or physician is in-network or out-of-network.