Methods and systems for disease management care coordination

Abstract

Methods and systems for disease management care coordination are described. In one embodiment, claim data associated with a prescription drug is integrated with additional health data from a plurality of data feeds received from a client device, a care coordination device, and a health management vendor device. The integrated data is targeted to identify a member. The integrated data associated with the member is transmitted to a patient evaluator device. The integrated data is updated using additional member information received from the patient evaluator device. Other methods and systems are described.

What is claimed is: 
     
         1 - 45 . (canceled) 
     
     
         46 . A method comprising:
 determining, on a computer processor, for each of a plurality of opportunity-available members a prescription drug spend, a number of concurrent open healthcare coordinator cases, and a pill burden threshold;   calculating, on the computer processor, for each of the plurality of opportunity-available members a predicted adherence risk score for a disease state;   calculating, on the computer processor, a total risk score for each of the plurality of opportunity-available members based on the prescription drug spend, the number of concurrent open healthcare coordinator cases, the pill burden threshold, and the predicted adherence risk score for the disease state;   selecting, on the computer processor, a high risk member portion among the plurality of opportunity-available members based on the total risk score for each of the plurality of opportunity-available members;   transmitting, on the computer processor, integrated data associated with the high risk member portion of the plurality of opportunity-available members to a patient evaluator device, the patient evaluator device associated with a patient evaluator;   updating, on the computer processor, the integrated data associated with a plan member using additional member information transmitted by the patient evaluator device to create updated integrated data, the additional member information including documentation of clinical outreach performed on the plan member by the patient evaluator, the plan member being among the high risk member portion of the plurality of opportunity-available members; and   generating, on the computer processor, a report reflecting patient evaluator outreach results based on the updated integrated data.   
     
     
         47 . The method of  claim 46 , further comprising:
 accessing targeting data including a plurality of clinical-defined queries; and   running the plurality of clinical-defined queries on population integrated data to identify the plurality of opportunity-available members as having an opportunity for clinical outreach, the population integrated data including the integrated data associated with the plan member.   
     
     
         48 . The method of  claim 47 , wherein running the plurality of clinical-defined queries on the integrated data associated with the member identifies a plurality of plan members having an opportunity for clinical outreach, the plurality of plan members including the plan member, wherein transmitting the integrated data associated with the plan member includes transmitting the integrated data associated with the plurality of plan members to the patient evaluator device, the method further comprising:
 receiving member identification of the plan member from the patient evaluator device,   wherein updating the integrated data associated with the plan member is based on receipt of the member identification.   
     
     
         49 . The method of  claim 47 , wherein a clinical-defined query of the plurality of clinical-defined queries includes patient-inclusive criteria, patient-exclusive criteria, or both patient-inclusive criteria and patient-exclusive criteria for member identification. 
     
     
         50 . The method of  claim 46 , further comprising:
 creating the integrated data associated with the plan member by associating prescription drug claim data of the plan member of a pharmacy benefit plan with additional health data of the plan member from a plurality of data feeds received from a client device associated with a plan client of a pharmacy benefit manager, a care coordination device associated with a care coordinator that facilitates communication among a plurality of healthcare entities to address population pharmacy issues on behalf of the plan client, and a health management vendor device associated with a health management vendor.   
     
     
         51 . The method of  claim 46 , further comprising:
 associating the plan member with a case designation based on identification of the plan member as having an opportunity for clinical outreach; and   assigning the case designation to the patient evaluator among a plurality of available patient evaluators.   
     
     
         52 . The method of  claim 49 , wherein assignment of the case designation is based on relative experience of the plurality of available patient evaluators, background of the plurality of available patient evaluators, case load of the plurality of available patient evaluators, or combinations thereof. 
     
     
         53 . The method of  claim 46 , further comprising:
 receiving an evaluation request from the patient evaluator device, the evaluation request identifying the plan member to be evaluated by the patient evaluator;   transmitting a patient profile to the patient evaluator device, the patient profile including trigger data and the integrated data associated with the plan member;   updating the patient profile using information received from the patient evaluator device; and   generating a response to the evaluation request based on updating the patient profile.   
     
     
         54 . The method of  claim 46 , further comprising:
 receiving the additional member information from the patient evaluator device,   wherein updating the integrated data is based on receipt of the additional member information.   
     
     
         55 . The method of  claim 46 , wherein a member population of the plan client includes the plurality of opportunity-available members and a plurality of additional members. 
     
     
         56 . A non-transitory machine-readable medium comprising instructions, which when executed by one or more processors, cause the one or more processors to perform the following operations:
 determine for each of a plurality of opportunity-available members a prescription drug spend, a number of concurrent open healthcare coordinator cases, and a pill burden threshold;   calculate for each of the plurality of opportunity-available members a predicted adherence risk score for a disease state;   calculate a total risk score for each of the plurality of opportunity-available members based on the prescription drug spend, the number of concurrent open healthcare coordinator cases, the pill burden threshold, and the predicted adherence risk score for the disease state;   select a high risk member portion among the plurality of opportunity-available members based on the total risk score for each of the plurality of opportunity-available members;   transmit integrated data associated with the high risk member portion of the plurality of opportunity-available members to a patient evaluator device, the patient evaluator device associated with a patient evaluator;   update the integrated data associated with a plan member using additional member information transmitted by the patient evaluator device to create updated integrated data, the additional member information including documentation of clinical outreach performed on the plan member by the patient evaluator, the plan member being among the high risk member portion of the plurality of opportunity-available members; and   generate a report reflecting patient evaluator outreach results based on the updated integrated data.