Care Management and Patient Relationships

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.
The new technologies that enable PROs and PGHD (e.g., sensors that detect whether Ruth takes food out of her refrigerator on a regular basis), generate important data outside of patients’ traditional care environments, sharing it with care teams to expand the depth, breadth, and continuity of information available to improve healthcare and outcomes.

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The 3 Must-Have Qualities of a Care Management System

Care management systems are defined in many ways, but the only effective system comprises three qualities:

1.) It’s comprehensive and includes a suite of tools to address all five core competencies of care management. 2.) It’s inclusive of all EMRs and other data sources to enable thorough communication and analysis. 3.) It’s analytics-driven design facilitates clinical decision making and workflow.

Ultimately, an effective system improves outcomes and becomes an indispensable tool for managing population health. This article describes what drives successful care management, and reveals a suite of applications that aid care team members and patients through advanced algorithms and embedded analytics. Learn how technology is helping to develop appropriate interventions and improve clinical and financial outcomes.

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How Care Management Improves Performance for Clinicians, Compliance with MACRA, and Outcomes for Patients Like Olivia

As the link between performance and reimbursement in healthcare continues to grow, effective care management is key. And two critical components of effective care management are analytical tools and a multidisciplinary approach:

  • Analytical tools help clinicians stratify patients by risk and need and make it easier to collaborate and coordinate care for patients (and monitor their progress over time).
  • A multidisciplinary approach broadens the support patients receive, engages both patients and their families in their care, and improves medication adherence (between 40 and 75 percent of older people do not take their medications at the right time or in the right amount).
Care management programs do more than make patients healthier and make it easier for clinicians to coordinate care for their patients—they also improve performance and compliance with MACRA: a quality payment model that requires physicians to focus on optimizing care of their chronic disease patients across the continuum in the inpatient and outpatient environment.

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How Care Management Will Save Richard’s Life—and Billions in Healthcare Costs

The patient outcome benefits of effective care management programs are indisputable, as are the numerous economic factors driving the long overdue industrywide shift toward care management and value-based payment (VBP) models. The National Health Expenditure Accounts (NHEA) estimates that U.S. healthcare spending reached $3.2 trillion in 2015 ($9,900 per person). And as of 2012, half of American adults (117 million people) had one or more chronic conditions—the most common, costly, and preventable of all health problems. The key to addressing these alarming, unacceptable, rapidly increasing expenditures and saving the nation hundreds of billions of dollars in healthcare costs is better care management and the continued transition from fee-for-service to VBP models.

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The Importance of Care Management Communication: Keisha’s Story

Ineffective communication between care providers is a major problem. According to the Joint Commission, 80 percent of serious medical errors involve miscommunication between caregivers during the transfer of patients. Care management teams need to place emphasis on good communication to effectively coordinate care and improve health outcomes. This point is illustrated by Keisha’s story, a patient who had a severe heart attack just two days after her catheterization was postponed due to incomplete information and miscommunication between her PCP, cardiologist, and nurse care manager.

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The Expanding Concept and Role of Care Management: Coordinating Care for Carlos

The healthcare industry is increasingly focusing on care management, and it shows—patients with serious illnesses and injuries are experiencing better outcomes and living longer. But more needs to be done, as demonstrated by Carlos, the patient in this article who was headed toward invasive, expensive care because he had trouble being compliant with his diabetes plan. Care must be coordinated across the continuum, and tailored to the patient. The role of care management is expanding and can become more effective than ever.

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The Six Care Management Challenges Healthcare Must Overcome

Most health systems struggle to succeed in care management. Whether it’s the frustrating, manual, fragmented processes or the ubiquitous lack of standardization in care management, health systems aren’t alone when it comes to the six care management challenges they struggle to overcome:

  1. Fragmentation
  2. Limited data access.
  3. Poor data quality.
  4. Limited involvement in IT and data governance.
  5. Lack of standardization.
  6. Limited visibility and transparency for program evaluation.
The consequences of these challenges are widespread, ranging from wasting valuable staff time to delaying patient entry into the right care management program. Although far from easy, overcoming these challenges is a must for the industry to achieve the Triple Aim. Fortunately, the future of care management—automated, streamlined, and patient centric—is bright.

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Patient-Centric Care Management Is a Strong Strategy

Care management is an important field in healthcare that ensures cost-effective, timely, and personalized care. Essentially, it gets the right care to the right patients at the right time. An effective care management system is defined by three components:

  1. The fundamental of patient-centered care: understanding each patient’s individual needs, developing relationships with them, and providing tailored care.
  2. The technology to deliver real-time data and support the workflows and processes of care management teams.
  3. A culture of continuous improvement integrated throughout the organization. A care management platform must be supported by best practices, analytics, and adoption to lead and sustain outcomes improvement.
This article explores the principles of good care management through these components, and through the eyes of a physician who understands the powerful impact of treating patients with one-to-one care.

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The Case for Care Management: Arline’s Story

Patients with complex care needs, like Arline in this real-life story, account for the highest percentage of costs. Yet, they aren’t necessarily receiving the best care. A care management program for these patients can make all the difference by helping patients and caregivers more effectively manage their health conditions. It takes time, effort, and the implementation of new care delivery models and support systems to realize those benefits, however.

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Introducing the Breakthrough Health Catalyst Care Management Product Suite

Health systems are faced with the challenge of doing more than just reducing costs and improving quality of care—they must maximize their Return on Engagement by identifying and working with the patients they’ll impact the most. Health Catalyst’s Care Management Suite promises to help systems identify and improve the outcomes for these patients by delivering a comprehensive population health approach that addresses the five critical parts of any successful care management program:

  1. Data Integration
  2. Patient Stratification and Intake
  3. Care Coordination
  4. Patient Engagement
  5. Performance Measurement
What’s unique about Care Management Suite is its innovative, multi-pronged approach. It’s a mobile-first, patient-centric, end-to-end solution designed to help healthcare organizations succeed in a value-based world.

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