iPatientCare Blog - How to improve outcomes with population health?

How to Improve Outcomes with Population Health?

The population health is not just a measurement of health outcomes but also the pattern of determinants. The determinants include medical care, public health interventions, and genetics. There is a focus on the conditions and factors that are correlated with each other and also influence the health of populations over the life course. It applies the knowledge to develop and implement policies and strategies to improve the health of the populations, after identifying systematic variations in their patterns of occurrence.

To manage their patients’ care, the interdisciplinary team of providers, care coordinators, and business analysts have a single source of truth that provides near-real time results – advanced applications. It aims towards a particular program. For example, Heart Failure advanced application is aimed at cardiovascular programs. This application focuses on providing data for health care system’s heart failure, and it aids in tracking and reporting to CMS. All the outcomes in these areas are identified and improved through the data surfaced in this application.

The benefits of such applications include:

  • To provide appropriate interventions to prevent readmission.
  • Increase in ability to identify the high-risk area.
  • Decreased readmission rates due to better tracking and improved transitions of care – follow-up reminders, primary care knowledge provider, medication etc.
  • Increased compliance with CMS-recommended medications for treatment procedures.

The healthcare delivery systems have to deal with the socioeconomic and social determinants of health. Due to this public health system have faces issues. Therefore, the healthcare delivery systems must build the skills to interact with and develop health intervention strategies keeping in mind all the social support services. The social support services that public health professionals are managing to reduce the progression of infectious diseases in the community includes:

  • Charitable and religious organizations
  • Programs to encourage better lifestyle
  • Healthy options for eating
  • Crime reduction
  • Environmental strategies – clean water and air
  • Affordable housing
  • Adequate dental care

There are some important data sets required for population health. As the healthcare is moving from traditional fee-for-service to value-based model that incorporates value into the payment equation, population health has a long way to cope up. Many health systems do not have the data and technology to support this transition, that is why it is required to have set of data that includes patient-reported outcomes, the accurate management of financial margins is allowed by the activity-based costing and social determinants of health data. This way an organization can achieve the aspirations of value-based care (creating better patient outcomes for an effective cost and managing populations of health).

While taking the measures on performance on quality and patient experience the system has to deploy new models of care to reduce the growth of health care costs and improve the care. The population health is the name given to the strategy that fulfills and commits in improving care and reducing health care costs. The population health is the collection of activities that is important in the way care is delivered to the patients. The resources and technology for the hospitals and practices are provided to implement the population health across all the phases of care. The activities are organized in some key areas such as:

  • Primary Care – It coordinates the care of patients with complex care needs.
  • Specialty Care – Improves care coordination between primary care and specialty practices and enhances access to specialty services.
  • Non-hospital Care – Provides home-based care for patients with acute illness and developing services to better manage transition of care.
  • Patient Engagement – It offers the providers and patient the tools to improve communication, education and patient self-care.

The centers of population health closely collaborate with quality, safety, and value. Population health strategies extends beyond the current episode-based framework of the patient care. The healthcare organizations that have already taken initiative with population health have discovered the high-risk patients found at a later stage (for example – obesity program) may not return the most improved or best possible outcomes. In other words, the outcomes are changed or intervened if there are highest-risk patients that are often beyond the ability to recover. While there are other practices that deliver better outcomes for those patients that are high at risk.

There are two strategies that population health must focus on – firstly, there is increase in the healthcare system’s ability to manage risk-based contracts and bundled payment. Everyone should be aware of margins at all times. There should be awareness of margins at all time as it includes making the healthcare organizations manage costs and understand cost in a population health.

The other sector is providing tools such as patient and member risk stratification, enrolling in risk-based plans and care communication among members of a patient’s care team; while building relationship and care management within. Just one approach does not work for all. Patients have to be capable and willing to participate in their own care to achieve the highest possible outcomes. Accordingly, the health system should form the strategies to reflect risk and distribute care management resources. Have developed solutions at iPatientCare just to help practices have different approaches.

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