Coordinating and managing health care services for older adults with two or more chronic diseases for improved population health requires establishing patient self-care and sustaining communication between patients, caregivers, and health care providers. Chronic Care Management (CCM) for population health includes care planning and using population-level measures for better health outcomes. Healthcare organizations that have the ability to obtain, review, and apply analytical data are well on their way to improving patient care coordination. Data analytics help providers to understand the individual and collective health care needs of the populations they serve.
The foundation for population health management includes identifying relevant populations and creating a strong intervention process and communication mechanism. Electronic medical records (EMR) and electronic documentation are important tools for CCM care teams. Care Managers can work alongside health care providers to define subpopulations, analyze patient outcomes and develop services based on changing patient needs. Care Managers can leverage community organizations (e.g. transportation supports, social services, and caregiver supports) for capacity expansion of care coordination.
Eighty percent of determinants for health outcomes is associated with factors outside of traditional boundaries of health care delivery. For example, health behaviors (e.g. dietary choices), social support (family, caregivers, friends), social and economic factors (employment, education, income), and physical environment (air quality, water quality). When healthcare delivery systems expand their interactions with patients to affect these determinants patient population health outcomes will improve.
CCM care teams can be vital to transitioning away from a traditional fee-for-service health care business model towards value-based care and value-based payment models. Partnering with the right chronic care management team that can provide patient-reported outcomes data, care planning and ongoing monitoring of patient risks and health can help an organization or practice achieve value-based care.
Appropriate health care management of older adults, particularly those with two or more chronic conditions creates better patient outcomes. Addressing care delivery team challenges and having ancillary systems that support the population health workflow such as patient portals, remote patient monitoring, telemedicine, care coordination care planning is essential to better practice management.
CCM Care Managers can help establish the proper framework for collaboration amongst providers, patients, family caregivers, social service organizations, payers, home care, labs and other stakeholders. This can lead to greater healthcare value and patient care.
Written by Joseph F. West, ScD on Thursday, 08 December 2016. Posted in Quality-Based Pay, Patient Engagement, Population Health Management, CCM