As the healthcare industry continues the shift toward value-based care, clinicians must rethink the way they treat not only individual patients but also entire demographics within their communities. Developing a proactive approach to preventing readmissions for the highest-risk patients will foster improved health outcomes and increase Medicare reimbursement rates, elevating quality of care and profitability at the same time. Population health management (PHM) maximizes profitability by creating strategic treatment plans based on knowledge of the patient's social, environmental, and health factors, making it one of the leading healthcare revenue trends.
This guide will discuss the importance of patient health management in today's healthcare climate and how it works in long-term post-acute care (LTPAC) and skilled nursing facilities (SNF). We'll also show the components that go into implementing a successful population health management strategy, and how electronic health records (EHR) can help execute it effectively.
The American Hospital Association defines population health management as:
"...the process of improving clinical health outcomes of a defined group of individuals through improved care coordination and patient engagement supported by appropriate financial and care models."
While traditional care models create treatment plans for individual patients, PHM looks at the shared characteristics of patients with similar conditions. For post-acute and SNF organizations, that means identifying the root causes of chronic health conditions for entire patient demographics, so that they can create a framework for how to treat those with common health needs.
PHM is about more than treating one patient at a time — it's about understanding the patterns that create chronic health conditions for high-risk demographics, and crafting a proactive approach to treating them. It rests on the four pillars that help clinicians achieve their core goals:
Chronic care management: Individuals with chronic diseases or comorbidities present the greatest clinical challenges and generate the highest portion of healthcare costs. Assigning a case manager can facilitate better care coordination, reducing readmissions as a result.
Quality and safety: By identifying the most high-risk populations and the causes of their chronic conditions, PHM finds creative ways to boost patient engagement, increase medication adherence, and elevate overall delivery of care.
Public health: Social determinants of health (SDOH) play a critical role in community health. Addressing factors such as food availability, air quality, adequate housing, and healthcare accessibility can significantly improve health outcomes, reduce readmissions, and reduce the cost of treating the highest-risk patient populations.
Health policy: Population health management programs can leverage their findings to influence public health policies, crafting initiatives and regulations that lead to a healthier world.
While legacy delivery models take a reactive approach to treating individual patients, population management health strategies survey the bigger picture of their healthcare communities. They prioritize preventive health and a proactive approach to meeting large-scale patient needs, supporting high-risk, high-cost patient groups in the ways they need most.
SNFs and LTPACs face a host of unique challenges that PHM can address. For example, these facilities often possess high-acuity patients who require frequent, specialized care. Population health management solutions can improve visibility by identifying these high-risk patients and providing ways to monitor their health progress.
SNF and LTPAC facilities can also struggle with data silos. Because many patients undergo treatment with outside specialists, it can be challenging to maintain real-time patient records. PHM solutions help break down these data silos and improve care coordination during transitions.
PHM also benefits healthcare organizations with their compliance efforts. For example, population health management software like ChartPath possesses multiple data collection functionalities, helping facilities secure sensitive patient health information (PHI) and demonstrating their adherence to regulatory standards in the event of an audit. The result is fewer compliance violations and greater profitability, a key part of your EHR system cost savings.
For PHM strategies to succeed, healthcare organizations must have a robust data pipeline that yields actionable insights for their operations. Centralized data aggregation is especially important for breaking down healthcare silos and coordinating patient care during transitions, as many patients receive treatments from other practices that may be outside your network. Real-time access is also essential for reducing response times and proactively identifying at-risk patients, so that they can get the care they need before a readmission occurs.
PHM depends upon collaboration from every member of a patient's health team. Proper data sharing prevents any oversights if patients receive treatment from other clinicians. It also fosters more team-based decision-making as clinicians plan the best treatment strategy for patients. The result is improved care quality, a smoother transition from hospitals to LTPACs or SNFs, and ultimately, a quicker return home for the patient.
Population health management tools facilitate the data sharing and analysis that drive better care coordination and community health initiatives. However, having the right tool is essential. Some functionalities you should look for when you choose between PHM tools are:
Automation: By automatically contacting high-risk patients and providing notifications about their patient care, PHM tools can reduce clinicians' workloads and allow them to spend more time on treatment. The result is less burnout and a faster response time to patient needs.
Reporting: The most effective health IT solutions have extensive reporting functionalities that provide insights about your patient populations. PHM reporting helps you discover common SDOH factors, identify the most at-risk populations, and demonstrate your compliance during an audit.
User-friendliness: Clinicians already face heavy workloads, and a clunky tool only makes them heavier. A PHM platform should be intuitive and compatible with other tools, providing a seamless user experience.
Intelligence: When equipped with AI, PHM technology can detect trends in demographics, support clinicians in their diagnoses, and predict outcomes based on an organization's current health data. Taken together, an AI-powered EHR for healthcare not only empowers providers to craft a more insightful treatment plan but also helps them address pressing health issues before they occur.
Interoperability: Disconnected tools make it harder to collect the data that PHM initiatives need for success, causing delays in care coordination and potential oversights. An interoperable PHM platform can connect with the other tools in your healthcare environment, enabling more accurate patient health analytics and better delivery of care.
By collecting, analyzing, and ethically sharing patient health information as well as key SDOH parameters, clinicians can collaborate and develop a systematic approach for delivering optimal care to the highest-risk health demographics. This strategy goes beyond individual treatment plans to proactively address the most pressing health needs of entire health populations, driving profitability and positive health outcomes. But it takes the right tool to pull it off.
ChartPath's industry-leading EHR solution equips healthcare organizations with the tools they need to formulate a comprehensive PHM framework that meets the needs of patients in their communities. The ChartPath platform enables real-time care coordination between clinicians and offers clinical decision support. Our data collection and analysis functionalities also facilitate high-risk patient tracking, ensuring that patients with the most pressing health needs won't slip through the cracks. The result is not only clearer visibility into your healthcare processes but also reduced costs, higher reimbursement rates, and better patient care.
Interested in seeing how PHM tools could benefit your setting? Schedule a live demo today to see what ChartPath can do.