Four steps to population health management: Step two — Manage care transitions

In our last blog, on “Four Steps to population health management“, we discussed the first step of population health management (PHM), optimizing management of your physician referral network. By using data analytics, you can get a snapshot of which specialists are providing the highest-quality care at the lowest cost.

perspectives-2a_100But there is another area that deserves analytic attention, too, and that is managing care transitions. By ensuring patients who leave the hospital — or move to a skilled nursing facility — receive the support they need, providers can help prevent costly readmissions.

Discharge instructions are often insufficient to ensure smooth care transitions. Many providers assume that certain variables will always work in patients’ favor, such as prescriptions will be affordable and the plan will be adhered to, or that follow-up visits with physicians will be easily available. Unfortunately, this is often not the case.

By engaging in post-discharge outreach, providers can help make patients’ transition more seamless. Complex care management programs with dedicated staff, such as care managers, social workers, pharmacists and behavioral health specialists, or those partnered with organizations that provide such programs, have proven most successful.

Analytics can help predict which patients need extra support. Applied to claims, clinical and abstracted data, this technology can spot care patterns that may be contributing to readmissions and identify clinical gaps, as well as provide outcomes data that shows the results of a transitions program.

One Texas health system had five hospitals with readmission rates that exceeded benchmarks. After launching an integrated transitions care management program, the health system’s telephonic engagement with patients discharged from an acute hospital stay rose to 74 percent from 45 percent. As a result, its system-wide readmission rate declined to 5.2 percent from 8.3 percent.

In our next blog post, we’ll look at the third step in PHM, investing in in-home intervention.

For an in-depth discussion on the four steps to population health management, download our white paper The Four Steps of Population Health Management.

One thought on “Four steps to population health management: Step two — Manage care transitions

  1. Nice to see that another care professional agrees on discharging or transfering to another center deserves the proper care and instructions. Readmissions can be costly and can simple mistakes. The more organized our staff is the more proficient the home health care services are that we provide.

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