Many healthcare organizations talk about engaging patients as part of their population health management (PHM) strategy. But, what does engagement mean, and is it sufficient in PHM? And what is the role of technology? A recent survey found that healthcare organizations are engaging people chiefly through patient portals, while less than half are using other technology tools to do so.
In prior blog posts, we’ve described the first two steps to successful PHM – understanding your population and helping them navigate to proactive care. We view the third step in this journey as activating people to better health. We use that term because we think organizations need to go beyond merely engaging patients via patient portals and other approaches to activating them to become the most important member of their care management team.
Connected technology promotes activation
Activating clinicians is typically a first step to engaging and activating patients. A good PHM platform can deliver actionable information into their workflow, helping them coordinate care for those at rising risk, provide clinical pathways and enable better visibility into the ‘white space’ of patient behavior between medical visits. Technology can arm care teams both with the data and analytics they need and digital tools that make it easier and less expensive to reach and engage patients.
Consumers may be more disposed to use technology to help manage their health than their clinicians are. The majority of American adults own a smartphone and fitness bands are the most popular wearables, arming them with the tools to track their health. Nonetheless, the challenges to getting people to take a more active role in their health are significant and require tailored approaches that take their risk levels and preferences into account.
That means developing appropriate action plans for all three of your subpopulations, not just the ones at highest risk. Your strategy should also address the healthy and the rising risk subgroups so you can drive a comprehensive PHM strategy. Some examples of activating each group follow.
- Activating the ‘frequent fliers’
Connected technology like telehealth can help healthcare organizations reduce utilization in the highest utilizer or ‘frequent flier’ population. A review study confirmed that remote monitoring that employs telemedicine and other connected devices can help clinicians detect small changes in health metrics for those living at home with chronic conditions like stroke, heart failure and pulmonary disease. For example, small weight gains in someone with heart failure can signal disease exacerbation; using an ecosystem of connected devices, clinicians can quickly intervene through telehealth or other cost-effective measures to prevent an ER visit or hospitalization.
Technology also can play a role in activating those with severe mental health issues to better self-manage their disease. The Dartmouth Centers for Health and Aging[i] gave patients tablets containing disease-specific education content and self-assessment tools that engaged them in better self-management of their symptoms. They achieved a 70% adherence rate and gave clinicians an early warning of any signs of relapse.
Banner Health in Phoenix, AZ, used a Philips telehealth-enabled program to manage the care of patients with five or more chronic conditions at home. After identifying these ‘frequent fliers,’ they assessed their workflows to determine how to improve care coordination efforts. Then, they designed tools and patient activation programs to deliver continuous, comprehensive and proactive services. Their results included reducing the overall cost of care by 34.5%, hospitalizations by 49.5%, number of days in the hospital by 50%, and the 30-day readmission rate by 75%.
- Activating the rising risk population
To activate the people in this rising risk group to better health, a robust analytics platform can help you accurately target and activate those who have or are at risk for conditions like metabolic and cardiovascular diseases. Studies have found that even small changes in weight can significantly reduce risk. This population can be activated to make lifestyle changes supported by a care team or by using technology-enabled employee programs. Providers can also activate them to take appropriate preventive measures such as aspirin therapy, smoking cessation and/or statins.
Statin treatment can significantly reduce the risk of developing cardiovascular disease in select populations. Newer guidelines recommend using low to moderate doses of statins in adults ages 40 to 75 without a history of cardiovascular disease but with at least a 10% risk of having a cardiovascular event in 10 years.
Even retail pharmacies like CVS Health are beginning to make chronic disease management programs part of their walk-in health services. Starting with people who have diabetes, they plan to help monitor blood sugar levels and support medication adherence and lifestyle changes.
- Activating the healthy population
For the healthier subgroup, a robust PHM program that incorporates evidence-based prevention programs, supported by connected devices and solutions, can help you activate them to stay healthier longer. Programs that include support for weight loss or maintenance, healthy habits like exercise and good nutrition, and human and digital coaching can help people avoid or reduce their risk of common metabolic or cardiovascular diseases.
Employer groups and insurers can also activate their physicians/employees/members to better health. MGM Resorts International identified members of its Direct Care Health Plan who were missing appropriate screenings, then activated physicians to increase the number of patients who were screened for lipids, diabetes and colorectal cancer by more than 25%. A U.K. insurance company provided prevention programs for those at risk for diabetes, succeeding in having 84% complete a prevention program and 64% losing 5% or more of their body weight.
Engaging people in actively managing their health is a challenging but hugely rewarding third step in the PHM journey. PHM platforms can provide the necessary data to target care interventions, and connected tools that include telehealth and smart phone applications can help to cost-effectively activate patients to better health.
To learn more about how your organization can successfully undertake the PHM journey, read our white paper, “Beyond frequent fliers: why healthcare organizations need a comprehensive PHM strategy.” If you missed our first two blogs in this series,
- Read The first step to comprehensive PHM: Understand your population
- Read The second step to comprehensive PHM: Navigating care for patients
[i] Adherence rate documented by Dartmouth team current as of 3/30/2017
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