When people need healthcare, they need to receive it in a way that is optimized. Optimization encompasses many things—not only delivering the appropriate care to help patients get healthy, but also finding the organizations and care providers that will provide the shortest path to success for the desired patient outcomes. When there is an intersection between the right care at the right time with the right organizations reaching the right patients, the experience and efficiency of care is optimized, and you take a major step toward Healthcare Solved.
In recent years, the industry has focused a lot of attention on using the EHR as the center of today’s healthcare delivery. While EHRs add value at the point of care, enabling caregivers within a care setting to chart and manage patient information and to administer organizational operation, we can’t stop there. Extending the applicability of the EHR through other population health management solutions will help us look beyond the point of care to get to the real goal—improving how we manage patients—by focusing on the between-care activities and settings to significantly impact patient outcomes. This approach will help us bridge the gaps and pull the maximum value from the EHR in the larger picture of longitudinal care.
Delivering effective care to high-risk populations is challenging. As the costliest patients to treat, at-risk patients—typically those with some combination of tough chronic diseases, complicated behavioral health issues, and adverse social conditions—strain the entire healthcare system, requiring treatment from many different providers and a large investment of time and resources. If patients are unemployed, uninsured, or uneducated, the impact of their conditions is magnified. These forces result in an epidemic of poor health in our disadvantaged communities.
While we know that outcomes can be materially impacted by non-clinical factors like social determinants of health, the industry’s strong focus on medical factors have long pushed social determinants to the backseat. It is clear that population health management is most effective when it is comprehensive and community-based, extending beyond the walls of a single care establishment to encompass all relevant services, including medical, behavioral, and socioeconomic factors. But what will truly make a difference to patients is being able to prescribe how to address the social determinants in a normalized manner that will consistently improve patient outcomes.
How the Digital Health Initiative of Philadelphia Began
Named the “poorest big city in America,” Philadelphia has plenty of challenges, and one of the most damaging is the impact on our poor communities in the area of healthcare. Philadelphia County has more than 500,000 Medicaid enrollees, and care for these vulnerable populations strains the entire healthcare system, diverting resources from other areas of investment that would otherwise benefit our region. Poverty costs us jobs, new business development, tourism, and other growth opportunities.
This blog is part 2 of a discussion of value-based care—the new paradigm in which care is no longer delivered only by doctors and nurses, but by an entire community of providers that treat the “whole” patient rather than just treating the disease. The focus is on treating the entirety of a patient’s needs to bring about better health outcomes—which means that communication and care plans no long reside solely within a doctor’s office. To achieve this objective, the industry is migrating to a de facto set of standards that it is believed will take us down the right path. Read more “Value-Based Care—The Future of Health Care: Part 2 of 2”
Value-based care creates a new paradigm—one in which care is no longer delivered only by doctors and nurses, but by an entire community of providers that treat the “whole” patient rather than just treating the disease. Communication and care plans can no longer live inside the four walls of a doctor’s office, but must integrate information from the community to fully address the needs of the patient and of the population. Further, those members of a patient’s care team must work together to deliver an effective and coordinated treatment experience. This blog—part 1 of a 2-part series—introduces the idea of value-based care, and discusses how integrating care coordination with robust analytics into a single platform provides the big picture of patient care, enabling efficient, collaborative care for diverse teams to treat complex populations. Part 1 is an introduction, intended for those starting to explore the idea of value-based care. Stay tuned for Part 2, which will be a deeper dive into some of the key issues facing the industry.
Remember the days when you had to use two different platforms for phone calls and for calendaring and task management? In today’s iPhone/Android laden world, such a separation seems heretical. Yet in healthcare’s hot new niche of population health management, we see that same heresy in the artificial, and suboptimal divide between care coordination/management software and analytic software. Read more “Care Coordination and Analytics Together”
Our previous posts have discussed the details of managing care team assignment and composition that’s customized for the whole patient as well as managing patient and population care systems. Now, we move onto the fourth and final discussion topic in this series for supporting a care coordination program using technology: measurement & reporting.
The last step in any effective process is to monitor progress, analyze results and make adjustments accordingly. But in order to track program success, you must start by implementing a measurement strategy that’s unified. Read more “Care Coordination Automation: Tracking Success, Part 4”
In our previous posts, we’ve discussed whole patient care and the use of technology to build coordinated care teams. Now it’s time to delve deeper and address how to leverage technological tools when treating and managing patients in a collaborative care setting.
Developing the right care plan for each patient requires the dedication of a multidisciplinary team, innovative technologies and an intimate connection with patients. Whole patient care means assembling a comprehensive network of healthcare providers – behaviorists, administrators, social workers, general physicians, payer care managers and specialists – and then assigning patients to the teams best suited to treat their individual conditions. Read more “Care Coordination Automation: Management Cycles, Part III”