In our last blog, we discussed the importance of helping patients make seamless transitions to their homes or another care facility following their stay in the hospital. Through care management programs supported by data analytics, providers can identify and help patients who need a little extra help — and prevent costly re-admissions.
The next step in population health management (PHM) is investing in in-home intervention.
High-acuity patients with chronic conditions such as diabetes, hypertension and lung disease are at high risk for admissions and re-admissions. Yet in a fee-for-service environment, providers often discharge these patients and hope for the best.
Patients with high-acuity, chronic conditions need additional clinical support. It’s clear that such high-acuity patients need more than just discharge instructions. In a value-based environment, they should be closely monitored post-discharge and targeted for intervention to keep them on the road to recovery.
The advent of value-based care has made “house calls” financially viable. Finding the right patients to target for in-home care starts with applying analytics to data. Organizations need to find the individuals who are driving a disproportionate share of the cost of care. This often necessitates applying highly accurate predictive models to the appropriate data.
Next comes the outreach — by phone, Internet, or in person — to the identified patients. Such outreach can be handled by home health agencies, social workers, nurses (including care managers), nurse practitioners and even physicians. Home visits give practitioners, especially social workers and care managers, first-hand knowledge of patient needs.
Other methods for intervention outside of an acute care environment include telephonic case management, wellness education and in-home monitoring.
In our next blog post, we’ll explore the fourth and final step in population health management, expanding chronic disease management to the full attributed population.
For an in-depth discussion on the four steps to population health management, download our white paper The Four Steps of Population Health Management.