One of the major challenges facing health care providers today is how to transform the national healthcare infrastructure from a volume based to a value based model - better outcomes. Additionally the goal is to provide closely coordinated, higher quality health care more cost effectively, while expanding access to services. Certainly these are incredibly challenging and complex issues. In this blog, I'll present some ideas as to how this paradigm shift can be supported.
One of the major challenges facing health care providers today is how to transform the national infrastructure from a volume based to a value based model - better outcomes. Additionally the goal is to provide closely coordinated, higher quality health care more cost effectively, while expanding access to services.
The passage of the HITECH Act and the Patient Protection and Affordable Care Act bring into law new requirements for reducing health care costs and provide for new paradigms that will focus around providing population health management.
The Patient Centered Medical Home (PCMH) and Accountable Care Organization (ACO) are at the center of this paradigm shift – integrating wellness with health care to drive better outcomes. One of the many challenges that health care providers face in implementing PCMH/ACO based model is the requirement of developing in-depth competency in population health management, an attribute not found in most provider organizations or their technology systems.
Part of what is needed to support this paradigm shift is a digital health technology platform that can provide health care organizations with the tools and resources they need to embrace the move to patient centered health delivery, including population health management, which is at the core of these models.
Specific requirements include:
Health care organizations must span inpatient and outpatient settings to provide a continuum of care to drive wellness. Methods to share patient information with multiple providers both within and outside of their environment must be supported.
Provide patient centered coaching in care transition, personal health management, and population wellness programs, including the technology platforms to support deployment of coach training for health care providers.
Patient communications, follow-up, and real-time monitoring must be delivered to provide health education, drive compliance with prescribed therapies, and alert care givers to adverse changes in patient wellbeing.
Care transition as patients leave acute care facilities must be coordinated with all care givers for each patient in order to avoid miscommunications that could produce adverse events.
Patient goal setting and tracking must be part on all deployments to insure that wellness programs can be measured for effectiveness and completeness.
The ability to implement analytic methodologies to support the collection, measurement and reporting on outcomes data. Also required is the ability to collect, measure and report on the health risks of the sponsor’s patient population that address the burden of avoidable morbidity and mortality.
Any successful system that delivers Population Health Management must provide a platform that supports the patient, health care providers/coaches and administrative process management team. The platform must provide care management tools, tracking, educational content, patient communications, and integration options. No small feat to provide, but efforts are underway across the country to move to this new model of health care delivery.