CareCompass

1. CareCompass
Helping complex patients navigate their health system

2. The Panel

3. Patient
Passport
Community
Care TeamSignal
The CareCompass
Aim: Reduce hospital admissions through integrated response to acute
events across complex care teams

4. Goal: Notify team of acute events in real-time
The Signal

5. Goal: Ease communication between patient, care team, and
auxiliary services
Care Team
Patient-Team IntraTeam
• CM
• MD
• Practice RN
• Practice staff
Team-Auxiliary
• Social Worker
• Pharmacist
• Community Resource
• Transportation staff
• Specialists

6. Goal: Coordinate patient needs with community resources
Community
Pharmacies
Hospitals
Community health centers
Shelters
Transportation (e.g. The Ride)

7. Goal: Centralize patient information for all caretakers
Passport
Clinical
Code status
Health care proxies
Specialists/current providers
Demographic
Address
Phone Number
Email
History
Chronic conditions
Allergies
Prior admissions

8. End of Journey
PatientEvent
Passport
Community
Care TeamSignal Destination
PCP
Urgent Care
ED
Pharmacy
SNF
Shelter
Family Van