Question

With the ultimate goal in mind – improving population health, what tools, systems, and technologies can the organization use?

Answer 1

Following tools and technologies are used by organization for improving population health-

Involve users in decision-making about technology investments and use- Include care coordinators from the start in planning new workflows and system designs to improve their job performance. As organizations move toward centralized care management systems, understanding care coordinators’ roles and responsibilities is necessary to achieving usable, familiar workflows that enhance productivity.

Automate workflows to effectively manage resources- According to researchers at Central Virginia Health Network and MedVirginia, healthcare organizations can quickly generate financial returns and maximize resources by replacing paper and manual processes with automated workflows. Many care coordinators are documenting notes on paper and then transcribing electronically, which wastes time. For example, two full-time equivalent workers were saved a week by automating patient caseload lists during a recent Beacon Partners’ project at a healthcare system. Another academic medical center was able to recognize significant savings through the use of patient care navigators, who were essential to reducing 30-day readmission penalties.

Use prospective quality reporting data to shape programs that identify high-risk populations’ needs- Tools are now available to shift from relying on retrospective data to near and real-time information, which provides actionable insight to make effective changes. For example, clinical dashboards can reveal if certain populations are refusing to receive flu immunizations, which can highlight the need to implement community health education programs to achieve outcomes quickly.

Recognize that health information exchanges (HIEs) and patient portals require efforts coordination mix- As the use of applications and mobile devices to access health information increases, healthcare organizations will need to assess how tools — such as Apple’s HealthKit — influence patients’ behavior and fit into the care coordination framework. Telemedicine monitoring and clinical data capturing on a near or real-time basis will also continue to grow as health systems look for ways to increase patient engagement. The need for real-time data from multiple disparate systems becomes increasingly critical to coordinating care so providers can intervene to prevent adverse health events. These systems are also effective with managing overall costs if you are in an accountable care organization (ACO) or in a risk-based sharing arrangement. With the ability to capture clinical, quality, and financial data from EMRs and claims – total costs of care coupled with complex algorithms can score and predict high-risk populations to target.

Establish realistic metrics to measure success- State and federal waiver programs provide incentive payment programs that reimburse based on achieving specified outcomes.

The Population Health Management Model- The main aim of pop health management is to improve health outcomes of groups of people by improving the quality of care, providing better access to care, and increasing preventive care. It has the potential to improve the health care system while at the same time making significant cost reductions.

The general model is based on utilizing teams of care givers such as care managers, attending physicians, a host of specialist providers, and the patients’ family members. One of the hallmarks of this model is its comprehensive nature and flexibility.

Pop health management has become more significant due to shifting reimbursement strategies, including performance-based compensation, and as more hospital resources are allocated to outpatient care in order to reduce readmissions.

But, the change in strategies to improve quality metrics across a stratified patient population requires stakeholders to leverage advances in technology, including identifying new or relevant metrics to measure outcomes of the target group, providing culturally competent patient support services, and using various forms of communication to engage patients how they want to be engaged. Population Health Management systems are made up of several platforms-

Population Health Intelligence Platforms- Population health intelligence platforms are used to provide plan administrators and care teams with secure cloud-based access to comprehensive financial and clinical information. These platforms access clinical data and other patient data from multiple sources. They also give users easy access to predictive analysis, population risk stratification, hospital admission data, disease registries and referral data. The platform seamlessly connects to data warehouses that store third-party information and should allow third-party applications to be integrated to increase the functionality with ease.

Medical Management Systems- Medical management systems combine people and information to create highly personalized and effective services that are used to manage acute care management, chronic care management, wellness management and utilization management. Accurate integrated data is used by population health systems to identify at-risk patients, track results, analyze care and support wellness management. This helps patients experience fewer hospital and emergency visits.

Risk Stratification- Risk stratification tools are used to identify different population needs across all levels of risk and design the appropriate interventions to address the needs of the population across the entire continuum. These tools use demographics, care patterns, medical conditions and resource utilization to stratify patients into five main categories namely episode of care patients; high risk patients; chronically ill patients; healthy patients but with conditions and healthy patients.

Patient Engagement- Patient engagement services help in motivating patients to become partners in their own healthcare. The aim at building supportive and long-lasting relationships and use third-party data to identify patient needs and foster active relationships between PCPs or other healthcare providers and patients.

Predictive Analytics- Predictive analytics tools are used to model medical conditions within population to identify high risk patients long before they require expensive care. Analytics is a useful tool in budget planning, as well.

Better Patient Access- Healthcare technology has grown immensely in its ability to target high risk populations. One the most dramatic uses of technology to reach patients with poor access to care involves the implementation of telehealth. Telehealth is a broad term used to refer to advances in use of healthcare technology in practitioner training, deliverance of services and continuing medical education.

These are the complete tools, systems and technologies that can be used by any organization to improve population health.