Care Coordination Automation: Management Cycles, Part III

whole patient careIn 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.

Management Cycles

True population health management involves two intersecting management cycles:

  1. Managing each individual patient’s care
  2. Managing entire patient populations through effective care coordination programs.

These management cycles must be thought of as distinct but symbiotic, feeding off of one another and promoting the same goals: health and wellbeing.

Each of these management cycles is comprised of the same fundamental steps:

  1. Design a plan.
  2. Execute your plan.
  3. Observe and record the results.
  4. Analyze your observations.
  5. Make adjustments to optimize subsequent cycles.

Let’s examine each cycle in turn.

Patient Care

It is essential to deliver effective care to every patient you see. That means a patient care management cycle should address performing a range of activities, potentially involving the entire care team across the care continuum. These activities should be coordinated among the care team members in such a way that the best possible outcome is achieved by the patient. Technology assists with this task in a number of ways, including but not limited to:

  • Providing for a unified care plan that all providers can contribute to and that serves as a common reference and platform for coordinated treatment activities
  • Enabling mechanisms for the care team to collaborate beyond just sharing patient data (e.g., tasking, scheduling, ad-hoc communication, etc.)
  • Alerting the care team to key patient activities and encounters, and linking those to the ability to take actions and interventions as appropriate
  • Allowing for documentation of the medical, behavioral and social determinants of health through customized and standardized assessment vehicles.

The ultimate goal in the patient care cycle is to consider what is an effective treatment plan for the patient and then enable the team to document, share and execute it.

Population Care

On a larger scale, your coordinated care program is meant to improve the overall health of the communities you serve. You need to create patient plans that, in the aggregate, also promote the wellbeing of the community. This involves developing processes within the communities to serve all patients and to deliver consistently high quality to each one. The individual patient treatment process may be structured to optimize the population management goals, thus ensuring that treatment on the individual level is intimately supportive of population care.

Even though patient care and population care intersect, population care adds parameters and concerns beyond a given patient’s individual outcome. A population care management cycle might also address questions such as:

  • What are the logistics of the clinical program that implements patient care, and how do we best accomplish them?
  • What are the overall goals for the program?
    • For example, are we aiming for lower readmission rates, earlier detection of disorders or lower overall incidence of a certain prevalent (possibly population-specific) disease, etc.?
    • Which organizations need to be included in the network for the most efficient and effective care coordination, and how well do they perform once admitted into the program?
    • What community involvement is required?
      • Which community members need to be connected with the plan? What are their responsibilities, and what roles do they play?
      • How much labor is required in order to make the system function, and which types?
      • What are the costs associated with the delivery of care under the coordinated care model?
      • Which policies need to be instituted, and how should they be enforced?
      • How are the patient populations defined and delineated?

These kinds of questions typically translate into the following groupings of population management functionality:

  • Observation is how the technology platform aids in capturing the data to observe the phenomena underlying the questions of interest.
  • Measurement is concerned with how the observation data is integrated into defined indicators, which are tracked to determine successful program implementation across various dimensions.
  • Configuration indicates the levers within the technology platform that enable program changes to be made and remain optimally supported.

Technology for population management, therefore, tends to be more analytically oriented, or concerned with data acquisition and processing.

Patient Care As A Subset Of Population Care

Understanding the distinction between managing a population and managing individual patients helps to design each process as its own entity. However, the interconnection of the two systems shouldn’t be forgotten, especially when it comes to making adjustments. When changes are made on the patient care level, they must be evaluated for impact on the overall population care level. Technology can make this easier or more difficult to manage, so tools used in your program should support these operational concepts inherently.

Stay tuned for Part IV of this series, which moves onto the measurement, reporting and analysis of care coordination.

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