Managing high-risk patient populations to improve outcomes

Doctor reading information off of a tablet

Population health management is a strategy that healthcare organizations use to improve the health outcomes of a defined group of people based on a hospital population, geographic area or specific disease. PHM relies on data to identify gaps in care and develop care plans that aim to close gaps and improve health outcomes. PHM aligns with value-based care, which emphasizes quality care to relieve the financial pressures on the U.S. healthcare system.

By implementing value-based care, healthcare organizations can better understand the total cost of care and the risk they currently assume — and will assume — for their patients.  According to a report from the U.S. Department of Health and Human Services’ Health Care Payment Learning and Action Network, 34% of healthcare payments in 2017 were tied to value-based care, up from 23% in 2015, indicating a steady trend toward patient and value-centered care.

The goal of PHM is to improve patient health by focusing on chronic disease management, wellness and prevention, and clinically integrated networks that encompass primary care providers, specialists and hospitals. These providers share health record systems and track data for at-risk cost structures, such as Medicare Advantage plans, Medicaid managed care and self-insured employee plans. Medicare Advantage plans receive payment from CMS based on beneficiaries’ Medicare Risk Adjustment Factor scores. The various diagnosis codes that providers submit help determine Medicare RAF scores, which are intended to motivate providers to keep patients healthy by improving these scores.

PHM Data Elements

Electronic health records
Electronic health records are patient medical information that has been collected and stored for use across clinical care and healthcare administration to help manage clinical workflows. They contain a wealth of patient information, including demographics, diagnoses, medications, vital signs, and laboratory data.

EHRs support clinical decision-making, health information exchange, electronic communication, patient support, administrative processes, and population health reporting. They contain patient identifiers — including patient name, date of birth, emergency contact, and other personal information.

EHR technology has been an important contributor to the increased collection of data in a consistent and quality manner. Unfortunately, EHRs effectively silo their data within individual practices and health systems, creating a key barrier to communication, care coordination and collaboration, and efficient health care delivery.

HIEs help to address silo barriers by allowing HIT systems and healthcare providers to exchange information that fosters high-quality, cost-effective care. The shift to value-based care and PHM has made HIEs an important and cost-effective way to improve care and outcomes for patient populations.

HIEs exchange clinical and administrative data types, usually from health systems to EHRs in the community for results delivery and use at the point of care. This includes a combination of narratives, such as hospital discharge summaries, and actionable data, such as lab results.

For this information to be useable, the data must be formatted and mapped to enable interoperability between systems and optimize the benefits of information exchange across systems and communities.

Claims data
Claims data includes information about patient demographics, billable charges, dates of service, diagnosis codes, procedure codes, insurance and providers. Claims are created after every patient encounter, which are submitted to a payer for reimbursement. Historically, payers and health systems have exclusively relied on claims data for analysis associated with PHM.

Claims data provides information about cost and utilization of a patient population across multiple care settings, as well as information about the types of diagnoses and procedures performed and insights into performance measures, such as mortality rates, complications, access to appropriate health services and charges for care provided. Too often, however, this data has limited use for quality and cost improvements.

Laboratory and pharmacy data
Lab data includes both lab orders and lab results. Currently, there is no mandated laboratory coding system for certified EHRs, and the majority of healthcare providers rely on local coding systems for lab orders/results. This limits the interoperability of multi-site EHR-derived lab data.

EHRs contain information on prescriptions that are written, while pharmacy claims data contain information on prescriptions that were filled. When EHR medication data are paired with pharmacy claims data, analysis leads to useful PHM information, such as medication adherence and reconciliation rates.

Hospitals and health systems
Healthcare providers often develop and manage EHR-based registries that are used to support clinical care and meet operational goals, facilitate clinical workflow, monitor quality metrics, enable disease/cohort management and offer PHM features. Effective PHM can ensure that resources go toward improving health outcomes for high-risk patients. This enables providers to focus on these patients to mitigate mortality and morbidity, cost, hospital and emergency department use.

Network data can be aggregated in a common data repository, such as an EHR’s data warehouse. Facilities that don’t use the same EHR platform face the challenge of unstandardized information. Standardized data is necessary for quality measures, disease management, PHM and public health reporting.

Social determinants of health data
Social determinants of health include smoking status, socio-economic status, housing conditions and economic instability — to name a few. These social variables are important factors for stakeholders to understand, given the potential health disparities that impact overall health.

SDOH data can help a provider assess treatment affordability or understand the array of treatment effects. Unfortunately, SDOH and behavioral data are not routinely or fully captured in EHRs. Also, SDOH data that could be imported from data sources, such as social services organizations, are usually missing in EHRs due to the lack of interoperability.

Significance and benefits of PHM

The United States spends more on healthcare per capita than any other developed nation. As the nation’s population ages — with the number of Americans aged 65 and older expected to double from 52 million in 2018 to 95 million by 2060 — the need for reform has become a growing imperative.

A successful PHM program helps healthcare providers better manage populations with chronic diseases, while preventive care helps reduce the chances of patients shifting into high-risk groups. Prevention also reduces emergency department visits, lowers hospital admissions and readmissions, and shortens hospital lengths of stay—a critical way to mitigate costs.

PHM informs evidence-based decisions based on data analysis, which assists in resource allocation across health care settings, improves the management of current and suspected conditions, identifies gaps in care, improves care coordination and lowers costs. Comprehensive PHM data provides insight into risk, incidence, prevalence and trends related to chronic diseases that can be compared with benchmarks across providers.

PHM enables providers to be more proactive with prevention measures and treatment. It also empowers patients to take greater ownership of their health and can help healthcare organizations to close gaps in care, enhance patient engagement, improve health outcomes for chronic disease and ensure greater financial sustainability.

The goal is to balance quality and cost for the delivery of patient care. Success hinges on utilizing the right EHR solution to collect and analyze the necessary comprehensive patient data in a way that delivers positive rewards for patients, providers, and plan sponsors.

PHM strategies

Rising healthcare expenditure and the growing need for value-based payment models are driving the adoption of PHM. In fact, the U.S. PHM market size is expected to expand at a compound annual growth rate of 20.5% by 2027. This has sparked demand for healthcare IT services and solutions that support value-based healthcare delivery.

Healthcare organizations looking to successfully implement a PHM program should consider key factors:

  • Data: EHR data and claims data play a key role in identifying patients with chronic illness who require more focused care, including SDOH information.
  • Predictive analytics: Powerful analytics tools help healthcare organizations determine which patients are at the highest risk of complications or hospitalizations and signal any need for at-home monitoring, medication management or palliative care.
  • Care management: This involves supporting patients across the continuum of care. For instance, a healthcare organization may launch a program of more focused care for high-risk patients to lower readmission rates or partner with the community to provide preventative care for homeless and/or uninsured patients to lower emergency room visits.

Using a combination of data, analytics and support staff helps to target patient populations that need more focused care — improving outcomes for patient populations and lowering costs. Finding the right PHM solution is critical for overcoming key challenges and achieving the promise of value-based care.

DataLink’s Evoke360

DataLink’s Evoke360 is a one-source solution that manages large amounts of data, offers a user-friendly interface and easy integration to deliver comprehensive data insights. It connects payers, management services organizations and providers to deliver quality improvement, risk adjustment accuracy, and optimized provider network performance.

As a comprehensive PHM solution, Evoke360 aggregates data from disparate sources, such as EHRs, HIEs, claims, labs, and pharmacy so that users can gain insights that result in a 360-degree view of the patient with real-time data transparency and patient-level drill-down dashboards.

Evoke360 effectively enables providers to identify open care gaps for proactive closure. A robust NCQA-certified HEDIS® engine is refreshed annually for the most accurate data. Evoke360’s risk adjustment engine manages current, projected and suspected conditions and calculates risk scores.

Evoke360 empowers better health using the interoperability of data sources and leverages payer-agnostic data in a meaningful use-certified point-of-care solution. With an 87% provider adoption rate, it improves provider workflow and reduces documentation duplication.

EvokeSmartVisit, a module within Evoke360, can be used at the point of care to document chronic conditions, close care gaps and track wellness goals. This module:

  • documents in-person and virtual health assessments
  • assists providers with documenting annual health assessments as required by CMS to ensure reimbursement for Medicare Advantage patients
  • offers a telehealth capability to enhance the patient experience by eliminating barriers related to access to care
  • helps provider practices improve care quality by identifying and proactively closing gaps in care
  • revalidates hierarchical condition categories data not originally captured from the patient’s medical record
  • creates transparency in managing utilization

With PHM, healthcare providers strive to manage patient care using a holistic approach and empower each patient with health information, as well as prevention and self-management tools. Evoke360 was designed to elevate PHM with value-based care insights from one source to meet the demands of today’s complex healthcare environment.

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