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Physician practices are the keystone to the healthcare industry’s shift to value-based care. Technology tools such data analytics and automated communication can help practices provide preventive care and assist with population health management duties.
In a value-based care environment, the responsibility to control costs and improve the outcomes for high-risk patients falls on physician practices. These population health management (PHM) duties can be major burdens on practices with limited resources and support staff, as they often require more than routine office visits to manage successfully.
Likewise, consumer expectations are changing. Patients want greater care accessibility and communication from their physicians. They are demanding information and answers when and where they want them. The key challenge for most practices is to continue innovating and working to further enhance the quality of care while keeping patients engaged and costs in check.
Maintaining engagement before, during, and after office visits requires organizations to monitor patient’s activities outside of the practice, in real-time. Activities include nonclinical events and factors that may influence outcomes. Fortunately for time-strapped practices, data-driven workflows and tools can help care managers and other clinicians more efficiently intervene with high-risk patients while increasing engagement and satisfaction for all.
The growth of high-deductible health plans and mobile internet-connected technology has changed patients’ expectations about healthcare. Patients experienced an 11 percent increase in out-of-pocket costs from 2016 to 2017, up to $1,813, according to findings from TransUnion Healthcare. Greater direct financial responsibility has caused many patients to consider new ways of reducing their costs and avoiding office visits-even if appointments are preventive or needed for chronic condition management. In fact, 40 percent of Americans reported skipping a recommended medical test or treatment and 44 percent said they did not seek care when they were sick or injured in the last year because of cost, according to a recent survey from NORC at the University of Chicago and West Health Institute.
Simultaneously, smartphone adoption rate has grown to 77 percent for all Americans and nearly half (46 percent) for Americans age 65 and older, according to the Pew Research Center. Smartphone adoption growth also means patients can access their devices to cost-effectively learn about and manage their chronic conditions, which can be helpful-or dangerous-considering the abundance of inaccurate and deceptive health information available on the internet.
While smartphones present a challenge for increasing engagement, they also offer an ideal opportunity for practices to activate patients in their care, through a device they’re already using. American consumers check their phone on average 47 times a day, according to Deloitte’s 2017 Global Mobile Consumer Survey. This means before a visit, automated health status surveys and reminders can be sent to patients’ via their phones. If a patient has not visited the practice within a predetermined amount of time, a text message urging the patient to schedule an appointment, complete a survey, or read education materials can be effective at sustaining or reigniting engagement.
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.
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.
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.