DMCN (Disease Management Coordination Network)​

Welcome to the future of client-centered care coordination with the Disease Management Coordination Network (DMCN) and DDIMTG’s innovative suite of products. Our community-based, client-centered, secure web-based DMCN application is redefining the way care is monitored and coordinated for specific client groups, including:

• Patients with chronic conditions like asthma, diabetes, and high blood pressure
• Perinatal mothers and infants participating in programs such as Nurse Family Partnership (NFP) and South Carolina Partners for Preterm Birth Prevention
• Patients within Patient Centered Care Medical Homes (PCMHs), Managed Care Organizations      (MCOs), Accountable Care Organizations (ACOs), or similar networks
• At-Risk Elderly patients or clients
• Underserved populations and those with limited healthcare access in rural communities
• Children engaged in early intervention programs
• Patients managing mental or physical illnesses
• Individuals enrolled in addiction rehabilitation programs
• Parents and teachers enrolled in children’s education, health, and/or social development programs

Disease management and care management programs require coordinated communication from multiple entities that interact with the client, including hospitals, emergency departments, physicians, and community care providers to maximize their ability to provide proper care and manage costs. The practical application of intelligent, decision-based information management strategies significantly extends a caregiver’s reach into the community. DMCN empowers care coordinators to collect client information from different points of care within the system, compile it, and apply "Integrated Outcomes" to coordinate care based on critical changes in a client’s condition or the occurrence of healthcare-related events.

DMCN’s ability to quickly process information and communicate it to the appropriate caregivers supports both caregivers and clients in managing the client's condition effectively, enhancing their quality of life, and preventing unnecessary incidents like hospital admissions. For instance, research indicates that patients who aren't seen by their primary care provider within thirty days of hospital discharge are ten times more likely to be readmitted. This risk is heightened when primary care providers are unaware of their patients' hospital admissions or discharge status.

At the heart of DMCN is a Master Patient Index (MPI). DMCN has software tools to electronically import, create, and manage the MPI with patient registry data supplied by the governing care coordination program. The registry for clients is typically provided by the program owner or a Primary Care Networks (PCN), which is set up to send the program’s patient or client registry data to DMCN periodically using secure transmissions. The schedule may be set up with each PCN and can be daily, weekly, monthly, or other designated intervals. The PCNs have the option of either sending (“Pushing”) their patient registry data to DMCN or having DMCN retrieve (“Pull”) the data directly from the PCN’s data storage location, usually through a secure File Transfer Protocol (FTP) communication. DMCN allows an unlimited number of patient identifiers to be created and tracked as part of the MPI, which is necessary with data coming from multiple disparate systems. 

Master Patient Identifiers (MPIs) within DMCN can include multiple medical record numbers, provider chart numbers, healthcare plan identifiers (such as Medicare ID, Medicaid ID, Plan Policy Numbers), and other unique patient identifiers. These identifiers are crucial for accurately matching healthcare events to the correct patient. The MPI matching algorithm prioritizes and utilizes these identifiers to ensure seamless processing of incoming healthcare events.

DMCN is equipped with a real-time Event Handler that continually monitors incoming healthcare events from external sources. These events typically include admissions, discharges, emergency room visits, and clinical visits reported by hospitals, but can encompass any patient healthcare event, such as data readings from home health appliances or remote monitoring devices. The Event Handler receives these real-time healthcare events from participating providers, including Health Level 7 (HL7) data interchanges, through secure communication channels. DMCN then matches these events to the Master Patient Index (MPI) and sends immediate alerts and notifications to the patient's assigned transition counselor and other authorized caregivers.

Experience the future of healthcare coordination with DMCN. Contact us to learn more about how DMCN can transform your organization.