Why Patient-Reported Outcomes Are the Future of Healthcare—and the Key to Ruth’s Independence

Patient-reported outcomes (PROs), defined as “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else,” are the future of healthcare. In addition to helping people like 80-year-old-Ruth continue to live interpedently, PROs—interchangeable with the term patient-generated health data (PGHD)—have several benefits:

1. Effectively supplement existing clinical data, filling in gaps in information and providing a more comprehensive picture of ongoing patient health.
2. Provide important information about how patients are doing between medical visits.
3. Gather information on an ongoing basis—rather than just one point in time—and provide information relevant to preventive and chronic care management.

Identifying Vulnerable Patients and Why They Matter

The vulnerable individuals in a health system’s patient population are at risk of becoming some of the organization’s most complex and costly members. Because vulnerability can be determined by long-term health status and social determinants of health (versus acute episodes), managing risk for these patients relies on a whole-person approach to care. Fee-for-service reimbursement hasn’t incentivized this comprehensive approach to care, but, under value-based payment models, health systems are increasingly rewarded for care that keeps patients well. The first challenge in addressing the needs of vulnerable patients is identifying those patients. Analytics-driven technologies can help health systems understand who is vulnerable in their populations and take actions to control risk for these patients.

Care Management Analytics: Six Ways Data Drives Program Success

To succeed in improving outcomes and lowering costs, care management leaders must begin by selecting the patients most likely to benefit from their programs. To identify the right high-risk and rising-risk patients, care managers need data from across the continuum of care and tools to help them access that knowledge when they need it. Analytics-driven technology helps care managers identify patients for their programs and manage their care to improve outcomes and lower costs in six key ways:

1. Identifies rising-risk patients.
2. Uses a specific social determinant assessment to capture factors beyond claims data.
3. Integrates EMR data to achieve quality measures.
4. Identifies patients for palliative or hospice care.
5. Identifies patients with chronic conditions.
6. Increases patient engagement.

Measuring the Value of Care Management: Five Tools to Show Impact

To earn legitimacy and resources within a healthcare organization, care management programs need objective, data-driven ways to demonstrate their success. The value of care management isn’t always obvious; while these programs may, in fact, be responsible for improvements in critical metrics, such as reducing readmissions, C-suite leaders need visibility into care management’s impact and processes to understand precisely how they’re improving care and lowering costs at their organizations. Five analytics-driven technologies give healthcare leaders a comprehensive understanding of care management performance:

1. The Patient Stratification Application
2. The Patient Intake Tool
3. The Care Coordination Application
4. The Care Companion Application
5. The Care Team Insights Tool

Five Data-driven Patient Empowerment Strategies

Data plays a big role toward empowering patients to become more involved in their care. With data, digital tools, and education, patient empowerment can act like a blockbuster drug to produce exceptional outcomes. Data empowers patients five ways:

1. Promotes patient engagement.
2. Produces patient-centered outcomes.
3. Helps patients practice self-care.
4. Improves communication with clinicians.
5. Leads to faster healing and independence.

10 Motivational Interviewing Strategies for Deeper Patient Engagement in Care Management

Care management programs are most successful when patients are deeply engaged in their own care. Using the motivational interviewing technique, care managers work with patients to identify personal care goals and motivators to follow the care management program. Ten strategies guide the motivational interviewing process, each focusing on patient-centered insights (e.g., pros and cons to following care management and barriers to adherence). With mobile technology to support these interactions, motivational interviewing can become a seamless, and vital, part of the care management workflow.

Custom Care Management Algorithms that Actually Reveal Risk

Care management is a tool for population health that focuses scarce healthcare resources on the sickest patients. Care management leaders need to know who those sickest patients are (or may be). The static risk models typically used for stratifying patients into risk categories only paint a partial picture of health and are ineffective for modern care management programs. Custom algorithms are now capable of predicting risk based on multiple risk models and multiple data sources. They help care management teams confidently stratify patient populations to paint a complete picture of care needs and efficiently deliver care to those who need it most. This article explains how custom algorithms work on static risk models to normalize risk scores and improve patient stratification, care management, and, ultimately, population health management.

Saving Lives: Effective Healthcare Communication Empowers Care Management

With an estimated 80 percent of medical errors resulting from miscommunication among healthcare teams, organizations can significantly improve outcomes with better communication. A communication methodology outlines the essential information clinicians need to share, giving care teams the knowledge they need, when they need it, to make informed treatment decisions. One communication toolkit, SBAR (Situation, Background, Assessment, Recommendation), defines the essential information clinicians must share when they hand off patient care from the inpatient to the ambulatory setting:

1. S (situation): The patient’s current situation.
2. B (background): Information about the current situation.
3. A (assessment): Assessment of the situation and background and potential treatment options.
4. R (recommendation): Recommended action.

Ten Essential Steps for Your Readmission Reduction Program

Effective care management is essential during the first 30 days after discharge to prevent unnecessary readmission and associated costs. Care managers can follow a 10-step readmission reduction program to help patients stay on track with recovery and avoid acute care:

1. Call the patient within two days of discharge.
2. Assess the patient’s self-care capacity.
3. Frontload homecare and ensure patient 'touches', if appropriate.
4. Conduct a home safety evaluation.
5. Order and install durable medical equipment prior to discharge.
6. Order an emergency alert/medication reminder system and preprogram important phone numbers on patient’s phone.
7. Implement fall prevention program, intervention, and education.
8. Provide in-home education on new diagnoses or unmanaged chronic conditions.
9. Connect the patient with community resources.
10. Establish a best practice for follow-up phone calls after discharge.

Transitional Care Management: Five Steps to Fewer Readmissions, Improved Quality, and Lower Cost

Reducing readmissions is an important metric for health systems, representing both quality of care across the continuum and cost management. Under the Affordable Care Act, organizations can be penalized for unreasonably high readmission rates, making initiatives to avoid re-hospitalization a quality and cost imperative. A transitional care management plan can help organizations avoid preventable readmissions by improving care through all levels in five steps:

1. Start discharge at the time of admission.
2. Ensure medication education, access, reconciliation, and adherence.
3. Arrange follow-up appointments.
4. Arrange home healthcare.
5. Have patients teach back the transitional care plan.

Population Health Documentary Highlights Three Success Stories Transforming Healthcare

The documentary, “A Coalition of the Willing: Data-Driven Population Health and Complex Care Innovation in Low-Income Communities” shows how precision medicine and care management can be effective tools for successful population health. The film highlights three programs that use data to hotspot populations of high-risk, high-need patients, and then deploy unique, targeted care management inventions. The documentary, which initially aired during the 2017 Healthcare Analytics Summit, presents hopeful solutions, scalable across diverse patient populations, that are leading to exceptional results and the future of healthcare transformation.

On the Population Health and Cost Transformation Stage, Care Management Is the Star

Joe’s story isn’t a unique one in the U.S. Having been admitted to the hospital five times in one month, Joe isn’t taking his medications and doesn’t exercise. In short, he struggles to follow his care plan. The Care Management Show, an entertaining, interactive theatrical performance, demonstrates why health systems need to adopt innovative, data-driven approaches to care management that prevent patients from falling through the cracks by integrating all aspects of patient care:

• Data integration.
• Patient stratification and intake.
• Care coordination.
• Patient engagement.
• Performance measurement.

Is Your Care Management Program Working: A Guide to ROI Challenges and Solutions

Care management programs play a large part in many health systems’ population health strategies. However, these programs can consume a lot of resources. It is important to know if a care program is effective, and eventually, to show a positive ROI. Many roadblocks stand in the way:

• Complexity of Environment
• Prolonged Time to ROI
• Lack of Access to Disparate Data
• Difficulty Engaging the Patient

Why Care Management Thrives with a Program Manager

As an improvement process, care management work is ongoing. This makes a program manager an essential role in the care management leadership team—along with a governance team and physician and nurse leader. From the initiation of care management to its maintenance, the program manager ensures that strategic initiatives are operationalized and sustained. Their responsibilities include:

• Overseeing ongoing program evaluation and improvement.
• Contributing to budget planning, justification, and approval.
• Overseeing change management and program maintenance.
• Overseeing ongoing expansions to the care program.

The Modern Care Management Team: Tools and Strategies Evolve, but the Outcomes Improvement Goal Remains

The care management team concept has evolved over the last decade to be more patient- and data-driven. Truly modern care management teams—those that represent the future of care management—provide team-based care that is carefully planned, comprehensive, highly coordinated, data driven, evidence based, seamless, and patient centric. But what’s equally important as being patient-centric and patient-driven, is relying on a comprehensive, effective care management system—a suite of tools with features in five core competencies:

1. Data integration.
2. Patient stratification and intake.
3. Care coordination.
4. Patient engagement.
5. Performance measurement.

A Guide to Care Management: Five Competencies Every Health System Must Have

The goal and responsibility of every healthcare organization and provider using a care management approach is to deliver the right care at the right time to the right patients. This standard of care management can only be achieved if five competencies are in place:

• Data Integration
• Patient Stratification and Intake
• Care Coordination
• Patient Engagement
• Performance Measurement