Holistic view of patients
Empowered with the right data, care managers can improve engagement during the office visit as well by ensuring all of patients’ relevant health concerns are discussed and their questions are answered. To guide this discussion, electronic health record (EHR) data is the foundation, but practices need broader insight into patients’ activity and behaviors.
A holistic view of patients includes information about their physical environment such as air and water quality, housing type, transportation, parks or walking access, and proximity to grocery stores. Behavioral information may be included in the EHR, but clinicians at the point of care need reliable insight such as care plan adherence behavior, healthy attitude, or behavior modifiability to optimize care plans. Social data is also crucial and may include information about the patients’ education, literacy, employment and financial history, family, and social support.
Data sets for these and other social determinants of health offer a view of patients that enable more relevant and effective care before, during, and after appointments. A better understanding of a high-risk patient’s social determinants of health also helps care managers overcome obstacles that may be affecting more than just one patient.
Automation and communication essential
Perhaps the most challenging time for practices to sustain engagement is after patients’ appointments. Advanced PHM technology can alert practices to outside clinical activities through integration to a hospital’s admission, discharge, and transfer (ADT) feed. This saves clinical support staff from checking the fax machine, sifting through multiple piles of paperwork, or manually entering hospital data into the practice’s EHR.
When ADT data and documentation from other area practices are captured, an advanced PHM platform can automatically analyze the information and alert the relevant care managers which patients require urgent follow-up. Such alerts can also help practices that do not have PHM-dedicated clinicians to better multitask and maintain productivity while improving quality.
Automated alerts can also be created through PHM technology to notify care managers if, for example, a patient misses a referral appointment or neglects to refill a prescription within a predetermined time frame. Once again, outreach and responses through the patient’s smartphone can then be run through a rules-based algorithm to help the practice’s care manager decide how to further intervene, such as a phone call, mobile survey to gather more information, educational materials, or in-person care.
The shift to proactive care
As the industry has shifted its focus from acute care to preventive care, physicians’ practices have had to take the lead. The increase in out-of-pocket spending, however, has made patients reluctant to visit the doctor or take advantage of benefits that are often covered under their health plans. Identifying potential health problems through integrated data analytics and launching automated outreach is helping practices take that leadership role a step further by shifting the focus from preventive to proactive care that boosts engagement and optimizes outcomes.
Gary Hamilton is chief executive officer of InteliChart.
