As we recently discussed, the first step for effective comprehensive population health management is understanding your population. But, where do you go from there? It’s not enough to simply know the current needs of the population and anticipate how they will change over time—you’ve got to help them navigate proactive, coordinated care they need to detect health problems early and stay as healthy as possible.
As we noted in our prior post, KLAS identified six IT functionalities that are necessary for successful PHM. One of those functionalities, Care Coordination/Health Improvement, ties nicely to this second step. At this step, organizations need to pinpoint gaps in care, and coordinate care by:
- Providing appropriate referrals
- Improving access
- Helping the organization transform its care delivery
Helping patients navigate to appropriate interventions not only will reduce utilization and costs, but it can improve your scores for MIPS, MACRA, your ACO, and many commercial payer quality scores. This is one way you can fund your ongoing progress in PHM/VBC.
To achieve a comprehensive PHM strategy that won’t put your program into the red over time, you need to navigate care for all your subpopulations, not just the high utilizers or ‘frequent fliers. You also need to navigate care for the rising risk population and those who are generally healthy. Let’s look at some examples of care navigation for each of these groups.
Navigating care for ‘frequent fliers’
Involving primary care teams is key for helping this subpopulation, commonly referred to as frequent fliers, navigate to appropriate care. Typically, these teams include a primary care physician who can serve as the ‘quarterback,’ supported by other caregivers such as nurses, nurse practitioners, care managers and physician assistants. Many providers have successfully employed the medical home model to improve care management for this group. Care managers play a key role in monitoring these patients and directing them to appropriate care before their medical conditions flair up and need emergency or acute care.
Navigating care for the rising risk
A comprehensive PHM solution can help those at rising risk for one or more chronic conditions to navigate to health interventions, screenings, and coaching programs. A surprising percentage of those with or at risk for chronic conditions aren’t aware. For example, most people with mild kidney damage don’t realize they have chronic kidney disease (CKD), and hypertension and diabetes often go undetected.
Let’s take CKD as an example of how a comprehensive PHM platform can help you identify patients at risk. You can use the platform to generate a list of those with a glomerular filtration rate (GFR) result below 60. Then, you can share this data with your providers so they can identify those with CKD and help them intervene as needed. For example, providers would be alerted to steer clear of anti-inflammatories and reduce the dosage of Allopurinol (used to treat gout) to avoid making the CKD worse
A similar approach can work with the many people who don’t know they have hypertension and other cardiovascular risk factors. A strong analytics platform can help your providers connect these patients with appropriate preventive measures such as aspirin therapy, blood pressure and cholesterol management, smoking cessation and/or statins. The data can also help clinicians employ newer care guidelines that show statins can reduce risk, allowing them to navigate appropriate statin usage in patients with a significant 10-year risk for cardiovascular disease even if they don’t have high cholesterol.
Navigating Care for the healthy subpopulation
Those who are healthy or have minor risk issues will need services that focus on guiding them to appropriate screenings and behaviors that will help them stay healthy. Your PHM program can direct them to appropriate cancer, cardiovascular and metabolic screenings to ensure that any emerging health issues are promptly detected. It can also help them navigate to programs that encourage healthy nutrition and weight, exercise and smoking cessation – and digital devices and coaching services can help to make these service more cost effective and continuously available.
VBC success: Navigating care to better outcomes
Let’s look at how three organizations have navigated care for patients to achieve better outcomes.
Philips Wellcentive worked with Blanchard Valley Health System‘s Medical Home Initiative, enabling the system to aggregate data from multiple sources into an actionable patient registry, identify gaps in care and deliver alerts to clinical statistics that allowed them to fill care gaps. The program served more than 4,000 enrollees, driving better management of high-risk and high-cost patients, greater preventive care compliance, and a drop in unnecessary ER utilization.
Philips Wellcentive’s end-to-end solution enabled the medical home to establish and maintain an effective care management program and better manage care transitions using nurse care navigators embedded in physician offices. As a result, Blanchard delivered an ROI of $2.44 per dollar expended, and reduce blood sugar levels, admissions, ER visits and charges for its diabetic population. They also achieved mammography and colonoscopy screening rates that significantly exceeded HEDIS benchmarks.
MGM Resorts International worked with Philips Wellcentive to aggregate data from 26 physicians and multiple data systems. That allowed them to identify which employees should receive health screenings, then enabled physicians to send them personalized messages that drove much higher screening rates. For example, lipid screening rates increased by nearly 29%, diabetes screening rates climbed to more than 25%, and colorectal screening rates increased to over 31%.
Up next as the final installment of this series, how to activate patient-consumers to take more control of their health.
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