Develop treatment plans. Assign tasks. Document care. Lightbeam’s integrated care management solution brings clarity that improves relationships and outcomes.
Lightbeam’s integrated care management solution drives positive relationships to support care plan compliance among patients. Whether working a care step, building a care plan, or documenting time for chronic care management, Lightbeam will help you coordinate care for the right patients at the right time.
Lightbeam’s integrated care management solution can deliver evidence-based, patient-specific care plans to each provider on a patient’s care team, providing you with the rules, structure, and content needed to drive care management programs.
Lightbeam’s care plans are created with the focus of organizing, analyzing, and providing the best solution to clinical teams to support your patient base.
Lightbeam’s ability to connect with health information exchanges (HIEs) allows you to access to patient records wherever care is delivered. You can engage care managers using patient data to deliver actionable utilization metrics in any setting.
In the last year, Lightbeam’s Clinical Transformation team has worked to help the care managers of Fairfield Community Health Partners, LLC (FCHP) build workflows and standardize reporting for their newly instituted care management program.
During these clinical transformation efforts, a FCHP nurse found and engaged a patient in dire need of assistance. Leveraging Lightbeam’s risk stratification methods, she identified a high-risk patient and obtained the life-saving medical supplies and care the patient lacked.
To learn more about this patient and the impact of the nurse’s intervention, download a copy of the story today.
After a hospital admission, I used Lightbeam’s cohorts to identify and contact a patient admitted to the hospital the day before. They had a history of gastroesophageal reflux disease (GERD), hypertension, vertigo, and reported metastatic colon cancer after colon resection. The patient went to the hospital due to significant weakness, fatigue, decreased intake of food and fluids, and difficulty performing basic activities. After their stay, the patient was discharged with home health in place. Unfortunately, the patient lived alone with no immediate family in the area and only one friend who would check in a few times a week. After determining the patient could not care for themself post-discharge due to increased weakness, I contacted them to create a care plan and complete a successful transition of care into their skilled nursing facility (SNF) of choice. The patient and their friend were very grateful for all the work we did to ensure a safe environment with access to care, and Lightbeam’s notification of admission accelerated what would have been a much longer process.
I was helping a high-risk patient after they were discharged from a stay in the hospital. The patient had a list of diagnoses, including type II diabetes, chronic kidney disease (CKD), chronic obstructive pulmonary disorder (COPD), coronary artery disease (CAD), multiple myeloma, arthritis, and anxiety. Using Lightbeam’s Care Management module, I created an individualized care plan and documented every service performed right in the patient’s profile. I called the patient and their spouse regularly every 3 to 4 weeks to check in. I learned that the patient’s spouse had difficulty determining the right foods to prepare for people that manage diabetes and renal problems. On top of that, the patient was having trouble swallowing. I discussed my proposed care plan with the patient’s physician, and they agreed that it was important to speak to a nutrition and diabetes education specialist. After learning helpful ideas for snacks and meals, the patient and their spouse feel more confident to manage their health at home and engage with me during follow-ups.
My particular role is to help patients and their families after discharge from hospitals or skilled nursing facilities. When I think about how much Lightbeam has helped me determine which patients need intervention the most, a particular situation comes to mind. Leveraging Lightbeam’s Care Management tools, my colleagues and I saw a patient in their 90s that was frequently admitted to the hospital. This patient’s only immediate family was their daughter, who lived out of state. I contacted the patient and their daughter and became their point of contact if they had any questions or concerns before going to the hospital automatically. The daughter called me daily, and we would review medications, help set up home health services, and eventually set up hospice care. I truly love being a care manager and impacting patients in positive ways like this, and Lightbeam simplifies the process greatly.
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