Overview > Objectives
CCBC partners have identified the following strategic, community-wide intervention objectives:
- Chronic Care Management includes a core set of interventions focused at the population-level within patient-centered medical homes. This initiative uses risk stratification, population-based registries and clinical decision support systems in electronic medical records and establishes care management standards and protocols to deliver effective, evidence-based care for patients with diabetes and cardiovascular disease.
- Transitions of Care is focused on improved care coordination across the health care delivery system to help ensure seamless transition of patients between primary care, specialty care and hospital-based settings. Examples include electronic notification of emergency department visits to primary care physicians and evidence-based specialty e-referral systems.
- The Greater New Orleans Health Information Exchange (GNOHIE) is a community-shared HIT infrastructure that will facilitate care coordination and chronic disease management by enhancing information and process linkages across health systems and improving the quality of care at the population level.
- Txt4health is a Mobile Health Technology that will use text messaging to provide the public with personalized education, diabetes risk assessments and follow-up messages.
CCBC is also collaborating with the Louisiana Health Information Technology (LHIT) Resource Center and Louisiana Health Information Exchange (LaHIE) programs to support other state and national level efforts focused on improving quality of care for the Greater New Orleans area.