Patient centered Medical Home (PCMH) Pilot - 86Borders/ConnectAllCare

86Borders is currently piloting its ConnectAllCare platform in Tennessee's PCMH (Patient Centered Medical Home) Value Based Medicaid program. The ConnectAllCare platform was implemented to provide PCMH providers and their care coordinators with a single platform for disparate data aggregation, enhanced patient engagement, and the collection/application/reporting of actionable data. 
COVID-19: Providers are integrating a COVID-19 screening questionnaire into their daily interaction with patients. The questionnaire can be administered via phone, SMS text, MyHealth mobile app, or in-person. Workflows/action steps can be tagged to patients based on the questionnaire's result. Data/results are gathered, aggregated and reportable in real-time, enabling appropriate actions.
Disparate Data Aggregation- EHR, State ADT/CareCoordinationTool Feeds, and Payer Data
Enhanced Patient Engagement- Patient tailored communications based on method preference (Phone, SMS, Email, Mobile App).
Actionable Data- Collection of structured actionable data on each patient allowing for administration of workflows based on the actionable data.
Goal: Implement a solution that enables the PCMH to improve its PCMH and HEDIS Quality and Efficiency metrics, increase overall patient/member engagement in primary care, and activate non-engaged patient/members.