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Monday, October 25, 2021
Home MedInsights Closing the Gaps & Improving Care: Why Patient Centric Data Matters.

Closing the Gaps & Improving Care: Why Patient Centric Data Matters.

By Dr. Sanjay Seth, Executive Vice President, HealthEC

Is it possible for disparities between population cohorts to be overcome or neutralized through technology? I believe the answer is yes. Over the past year, COVID-19 has magnified the gaps in healthcare on a large scale. We see this in higher rates of the virus in people of color, through the access or lack thereof to testing sites in poverty-stricken neighborhoods and especially in vaccine distribution among Caucasians verses minority groups.

The facts force us to ask ourselves, what does population health have to do with it? How can technology really change the outcome of a person’s health? And, if 80% of the nation’s health care dollars are spent on 20% of the population, how do we as healthcare leaders use technology and the resources at hand to do better? In this article I attempt to answer these questions and provide guidance for those leaders looking to make a change.

Using a Patient Centric Data Model

Part of the challenge physicians face is ensuring every patient who walks through the door is given the same quality of care. It’s no easy task, but over the years data collection has improved significantly to enhance the identification of factors that could influence the overall outcome and make success in a reimbursement environment of a value-based care model more feasible.

In order for this to work, let the data be your guide. This approach can be based on a number of factors, including:

  • Life circumstance intelligence metrics
  • Predictive risk, predictive cost, resources utilization
  • High or rising risk with mental health comorbidities
  • High-ER users and non-emergent use of ER
  • Frequently admitted patients or admissions for low acuity
  • Focus on chronic disease, mental illness or behavioral health
  • Mental Health Diagnosis
  • Medication adherence rates
  • Quality measured as gaps in care,score improvement

Many of the reasons that influence these factors can be determined through a Social Determinants of Health (SDoH) assessment on the front-end. These assessments include screening for housing, employment, food security, transportation and other indicators that greatly influence a person’s ability to access or even have the awareness to seek care impacting their overall health. It all comes back to identifying the right reasons, at the right time and at the right place.

Identifying the Greatest Risk

Once physicians are provided with the data,analyzed to easily identify the obvious,the reliance on data becomes acceptable and it becomes easier to see which patients are in the greatest need. Stratifying patients is not only critical for care but it’s also vital for reimbursement and prevention of utilization of appropriate resources down the road. Having data in one place, like through a population health management (PHM) tool, enables physicians to work off of the same data points so there’s no confusion.

There’s no doubt that high-risk patients come at a higher cost, and it’s extremely important to meet patients where they are so you can close the gaps in the care they have received so far. Working with the data allows physicians to bring at-need patients to the top of the funnel as well as identify those that would benefit fromincorporating community-based providers and services into their care plans.

Holding Patients Accountable

When patients are teamed up with the right provider to treat their specific need, it becomes much easier for the problem to get resolved. An example of an issue that often drains staff and resources at the community level is seen in chronic diseases. Many of these diseases, such as heart disease, stroke and high cholesterol, can be resolved with some lifestyle changes and better habits. The collaborative approach with the patient to create self-management plans with easily identifiable and achievable goals will make the management of some of the chronic illnesses easier and give the patient an opportunity to recognize their contribution to better outcomes.

For example,say you’re a 42-year-old single mother of three, and the sole caregiver and breadwinner in the household. Your days are spent getting the kids ready for school, going to work, picking up the kids, and going home to do it all again the next day. It shouldn’t be shocking that this same woman struggles with hypertension and obesity.

What the physician doesn’t want to see happen is this same individual suffer from a heart attack or fall victim to diabetes. PHM comes into play by offering the woman a care plan that fills in the gaps: a nutritionist to help her identify healthy eating habits, after-school care programming for the kids so she can make time to exercise after work, and guidance for establishing healthy routines to better everyone at home.

Lastly, a good physician should offer opportunities for:

  • Appointment follow-up
  • Medication alerts
  • Care Plan follow-up
  • Patient education leading to a self-management plan
  • Test result out of range alerts and changes that could minimize this occurrence
  • Access to their own customized data, easily interpret-able and with positive suggestions on the analyzed data

AICNY Helps IDD Community While Decreasing Costs

An example I’d like to leave you with pertains to AICNY, the Alliance for Integrated Care of New York. AICNY is an Affordable Care Organization (ACO) that oversees the healthcare needs of individuals with intellectual and developmental disabilities (IDDs). AICNY sought PHM technology to support a value-based model that manages the risk of those within their population across seven community health centers. Some of their goals were:

  • Identify and implement technology to create a central view of the patient’s data
  • Engage the physician community and illustrate opportunities for improved care
  • Manage care coordination and personalize patient communication for SDoH
  • Reduce overall cost to serve a growing beneficiary population and geographic region
  • Provide a solution to prevent unnecessary visits to the ER and hospital

Despite some challenges to start, AICNY used the data made available to them to reduce total costs by $2.4 million. Along the way, they were also able to work at the community level to engage approximately 30 providers to serve 1,000 of the organization’s riskiest patients. In addition, tele-triage kiosks have been installed in IDD group homes which have resulted in a 40% decrease in ER visits between 2019 and 2020 with a 7% reduction in ER admissions.

An equalized, value-based healthcare system is possible, as the case of AICNY demonstrates.The disparity in the incidence and mortality rates during theCOVID-19 pandemic highlighted the gap in healthcare but using a patient centricdata model can bridge the gaps in access and care to the benefit of all patients, regardless of the population cohort.


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