For many physicians, the demands of their extremely busy schedules make it a challenge for them to consistency reach out and engage their patients between visits. There are many lower-level clinical tasks that can be performed by non-physicians or can be automated. So in any organization focused on population health and care management, it is important that each member of the care team work “at the top of their license.” This helps the team as a whole scale up and become more effective. It really becomes a 1+1=5 situation.
In some healthcare organizations, care managers focus mainly on telephonic management of high-risk patients who may be admitted to the hospital or go the emergency department unless their urgent needs are met. This is an important task of the care team, but it is only one component of population health management. Of the patients who generate the highest costs in a given year, less than 30 percent were in that category a year earlier. So an organization that hopes to improve the quality and lower the cost of care must pay attention to its entire population.
Maintaining continuous contact with every patient in a practice, however, is a task that exceeds the capability of even the largest healthcare organizations if they use only manual processes. Care managers are expensive, and the number of patients they can help is limited. To expand their reach and the influence of physicians on their patients, some degree of automation is required.
Patient Outreach
Many patients experience gaps in their preventive and chronic care. In some cases, this is because they haven’t visited the practice in a long time. In other cases, their may not have been time for a discussion of these services during an office visit, or perhaps they haven’t followed their physician’s recommendations.
Some practices try to contact patients with care gaps between visits. But, even if a practice has a good system for identifying these patients, manual outreach is prohibitively costly in terms of staff time and phone and mailing costs. So this is usually a hit-or-miss process, and it is not scalable to larger groups.
New automation tools can facilitate this part of the patient engagement process and ensure outreach to all patients who need services. Using data extracted from a practice management system or an electronic health record, these solutions build patient registries and use clinical protocols to trigger messaging to patients who need to make an appointment with their physician. Frequently, this messaging results in patients getting back in touch with their physicians after a long absence.
A study at Prevea Health, a large multispecialty group in Green Bay, Wisc., showed that automated outreach to noncompliant patients with diabetes or hypertension increases the likelihood that those patients will make office visits and get the care they need. The study concluded, “An automated identification and outreach program can be an effective means to supplement existing practice patterns to ensure that patients with chronic conditions in need of care receive the necessary treatment.”
Risk Stratification
The majority of high-cost patients today had a much lower risk of generating high costs a year ago. So organizations that want to engage in population health management must adopt techniques that identify patients who are likely to become high risk and prioritize care management of those patients.
Some health insurers plan to give accountable care organizations predictive modeling software—similar to the programs their actuaries use—to accomplish that task. But it is also possible to do risk stratification—while also increasing patient engagement—by asking patients to complete online health risk assessments (HRAs), just as many employers and health plans do. Though patients resist filling out long forms, practices can break up HRAs into smaller, bite-size chunks about specific areas of patients’ health behavior, such as diet, exercise or smoking.
HRAs enable organizations to classify patients by their health conditions, health behaviors, and functional status. This helps providers spot patients who may become high risk and gives them data for analyzing their patient population. In addition, some HRAs measure stages of patient activation, which enables early intervention with patients who lack the skills to self-manage before they inevitably move to a higher health-risk group.
Conclusion
Care teams provide the non-visit, continuous care that is essential to population health management. They are also responsible for promoting patient engagement between visits. But, care managers who use manual processes cannot intervene with every patient. That effort requires the use of health information and communication tools that automate the process so that care managers can devote themselves to the patients who need the most attention.
Besides automating care management, the latest technologies enable organizations to analyze population data and stratify patients by risk. Based on that information, they can design engagement strategies tailored to particular subgroups of patients.
Learn More
Listen to a short video that explains how Prevea Health implemented a automated care management program from Phytel.