In my training, I spent years learning how to diagnose and treat patients, focusing on a patient when she was in the hospital or my office. At the time, providers were not generally trained, structured, nor incentivized to help the patient achieve the desired outcomes once the patient left the hospital or clinic. Readmissions would be attributed to "yet another non-compliant patient." A patient lost to follow up was not deemed the responsibility of the provider or the health system.
The practice of medicine has changed dramatically.
Fueled by rising healthcare costs, the population health trend continues to gain momentum. The era of fragmented fee-for-service care delivery that bears no responsibility for outcomes is ending. Instead, the movement to manage the health of patient populations—delivering high quality care at a low cost—is coming of age. While techniques such as risk stratification (identifying patients most in need of care) and care management (managing patient health-focused interventions) have been historically deployed by payers, providers are beginning to share economic incentives to deliver high-quality care at the lowest possible cost.
Today's providers are being challenged in unprecedented ways. As the shift to value-based reimbursement requires that they assume greater responsibility for care outcomes, providers must find new ways to engage and partner with their patients. To achieve population health success, providers must actively identify and manage issues beyond the patient's immediate clinical needs. For example, barriers to care, such as basic living, transportation, economic and education needs, impact patient health and prevent patients from realizing optimal outcomes. In addition, patients benefit greatly from a trusted advocate who can coordinate and reconcile the information and recommendations from the many providers contributing to the patient's care. Frequently, the patients most in need of change have limited opportunity and resources to do so. How can providers successfully partner with these at-risk patients and help the patient successfully follow a single, unified care plan tailored to their unique conditions and needs?
Provider-oriented care management is one solution. Care managers, with guidance from the physician, assess patient needs, determine gaps and barriers to care, apply appropriate interventions and coordinate care across providers and settings. At the same time, care managers connect and partner with patients in a way that educates and motivates them to take greater responsibility for their health. To accomplish these activities at scale, care managers need assistance to create individualized care plans, remain updated on the latest patient events, and manage tasks for a large volume of patients.
A comprehensive, patient-centered care management platform is central to helping providers and care managers actively manage their patients to achieve high quality, low cost outcomes. Automated care management platforms that create unified, evidence-based care plans that address each patient's unique set of conditions and offer provider-oriented workflows can help the entire care team manage their patient population. Healthcare organizations can now give care managers the clarity and confidence they need to improve patient lives—and begin to deliver the rewards of population health.
Read the eBook, Reimagining Provider-based Care Management, to learn more.