This article was originally published by Becker’s Health IT.
As many as 67 percent of healthcare organizations reported that they have population health management programs in place.1
The risk facing Accountable Care Organizations (ACOs) and other providers with population health management programs may be the emphasis on data analysis and risk stratification. Analytics, dashboards and automated patient-outreach efforts, while important, can cause providers to lose sight of the individual patient, especially when she or he returns home from hospital and are left to manage a complex, chronic condition or recovery alone.
Ensuring adherence to a chronic condition management or recovery plan requires patient engagement, which means individual time and attention. With smartphone penetration now reaching 77 percent of Americans,2 particularly gaining among older populations, mobile technology is emerging as a viable bridge that organizations can utilize to connect care teams to each other as well as patients at home.
Through their mobile device, patients can stay connected with their care team after discharge through daily check-ins and updates with personal care liaison. The result is patient populations who are activated and engaged in their care to improve their outcomes. These engaged patients can help hospitals improve quality metrics, such as reducing preventable readmissions and unnecessary care, which, in turn, reduces costs to maximize revenue under ACO and value-based payment models.
Connecting care teams through mobile
Before linking patients to their care team through their mobile device, connecting care teams themselves, also through mobile, is the first step to improving population health management results. Most care teams in hospitals today cannot effectively communicate and collaborate on patient care and discharge instructions because they are not in the same location and the data they need to make evidence-based care decisions is not easily accessible.
Teams are left with numerous different mobile communications devices and EHR workstations are usually away from the point-of-care, so communicating with the team about the patient’s instructions must be done away from the bedside. Through smart, mobile technology that clinicians carry with them, clinicians can have access to data from the EHR, plus communications tools to collaborate all on one device.
With mobile technology, developing, reviewing or adjusting patient discharge care plans in near real-time is feasible from the point-of-care, or whenever convenient, instead of after a shift or a round. Mobile also allows care-team members, who may not be located in the hospital, to consult and support clinicians through secure text messages or phone calls at bedside where they may be actively fielding questions or concerns from the soon-to-be discharged patient.
Empowering the patient before discharge
Once care-plan and discharge instructions are developed, clinicians in the hospital can enroll patients in a 30-day or longer readmission prevention or care coordination program that utilizes their mobile device. While still in the hospital, the engagement process can begin by forging that link with the patients’ mobile device that is likely already deeply engrained in their lifestyle and may be their only source of online access.3
At discharge, patients are educated about the discharge program elements, which may include daily phone call follow-ups for a month with a care liaison representing the hospital or check-ins through a smartphone app that is synched with the patient’s smart device, the liaison care management platform, and the hospital’s information systems.
During education, clinicians and patients can view the chronic-condition management and/or recovery plan on their personal mobile device for reference, so patients have hands-on experience using the app before discharge, which is essential for adoption. In addition, unlike spoken or printed instructions, a care plan on their smart device will not be forgotten or misplaced at home.
With the in-hospital education and collaboration on the discharge plan, the patient is no longer passively receiving instructions, but rather empowered to participate in the recovery and/or chronic-condition management.
Coordinating care and overcoming obstacles
On their first day home, the patient receives the initial phone call from the care liaison to review the discharge program and care-team instructions. Items that may be discussed include a review of newly prescribed medications from the hospital, but also existing chronic condition management therapies. Liaisons may also offer preparation support for scheduled physical therapy or rehabilitation appointments and other follow-up visits with physicians. In this initial call, a relationship is forged between the patient and the care liaison, who will address all the patient’s health concerns and questions over the program as well as confer with the care team to overcome any obstacles.
For example, if scheduling appointments has been a challenge for the patient, the care liaison can serve as a conduit between the patient and physician’s office or rehabilitation facility to arrive at convenient time for the patient. The care liaison can also help arrange transportation to these visits, if necessary.
When a question or concern needs to be shared with the care team, liaisons can upload that information to the application on the team’s smart, mobile technology. On their devices, the team can collaborate and adjust the plan as needed. Throughout the post-discharge period, they remain updated based liaison documentation about follow-up appointments and patients’ adherence to their plan. Depending on the question or concern from patients through their daily check-ins, the team can also collaborate through their mobile technology on the best evidence-based intervention.
Engagement is further supported through the patients’ mobile application where they can review their discharge plan, appointments and other medical information, but they can also conduct the daily check-ins to review potential symptoms, enter vital information such as blood pressure, weight or heart rate, and confirm that medications have been taken.
Through daily phone follow-ups or check-ins through the mobile application, the care liaison can better monitor recovery and adherence. For example, the application can automatically alert the liaison, based on pre-determined parameters, of a potential needed clinical intervention before adverse events occur. This added layer of oversight reduces financial and care-quality risk for providers and payers by helping to avoid a readmission or emergency department visit.
Improved population engagement and care plan adherence
Effective population health management requires integrated health information systems and data analytics to identify and intervene with high-risk patients. While this macro-level is important, so is the micro-level: engaging patients individually and at home. Thanks to their ubiquity in our lives, smartphones and other mobile devices can be an effective method to engage the individual patient and support the data capture, analysis and exchange required to manage populations.
When the patient information is linked to the care team’s mobile technology, collaboration is more efficient, less tethered to the EHR, but equally as data-driven. Most importantly, through personal mobile technology, the patient becomes an active participant in their recovery or chronic-condition management. This can lead to stronger care-plan adherence, a reduction in avoidable readmissions and fewer emergency department visits. For ACOs and other risk-bearing provider organizations, reducing these unnecessary costs and improving quality metrics through better patient engagement translates to greater revenue.