Implementing the Four Pillars for Managing Population Health

Care Coordination

Healthcare and social service providers are coming together to create community-based solutions that address the social determinants of health that drive population health. In a recent article in the Pharma & Life Sciences CIO Review online publication, William Feaster, Chief Medical Information Officer for Children’s Hospital of Orange County described his “four pillars of population health” that will improve the care experience for clients, reduce per-capita costs, and improve the health of populations.

Pillar 1: Care Communications

Communication is the key to preventing misunderstandings, mistakes and redundancies in care. A Harris Poll survey found over 95 percent of healthcare professionals believe improved communications between care collaborators leads to positive population health management results like reduced readmissions.

Currently, over two-thirds of providers feel care gets delayed when waiting for client information, and 72 percent of clinicians said they’ve wasted time trying to figure out who to speak within a wider care team.

When a care provider needs to make a decision in regard to a client, the organization needs a Comprehensive Health Record that includes all relevant data provided by insurance carriers, doctors, therapists, community providers, and any other stakeholders. Prioritizing rapid and effective communication is the first step to population health management.

Pillar 2: Patient Engagement

Communication must include the client as well. Clients need to take an active part in their own health. They need to know the details of treatments, coverage plans and educational materials available to them to maintain control of their health and manage their treatments.

Providers can use mobile devices during in-person visits to provide accurate data during every engagement. Online engagement portals are an effective avenue for distributing data to the public. Not only does it connect clients to a centralized information resource, but it appeals to individuals operating in a self-service economy. Clients want to find answers themselves and communicate with caregivers on platforms they find most convenient.

Pillar 3: Technology

While a large percentage of human service providers use online portals, conventional communication channels are still more popular than innovative solutions. Over 80 percent of organizations trying to implement population health management strategies rely on phone communication, but only about a third use remote and mobile technologies.

This is a problem because CIO Review said integrated technology solutions were paramount to effective population health management prioritization. Each of the four pillars should be backed by the right technology. Fast Company detailed how patient monitoring devices rapidly evolve to capture health data from every possible population segment while they engage in their daily activities. These insights are critical to creating an accurate picture of a client’s overall health and developing predictive analytics for future care.

With the right information, health and social service providers can advise actions and plan care strategies that prevent future hospital stays and emergency room visits. Case management software can help visualize client data while providing alerts when preventative action must be taken.

Pillar 4: Care Management

Informed decisions should play an important part in a client’s ongoing care. For example, readmission of congestive heart failure patients is a common occurrence. Health Affairs reported proper management of clients reduces readmission 90 days after initial treatment in 80 percent of cases. Continuing to prioritize clients’ needs prevents costly incidents and health concerns.

Clients need information when they leave a care center. Case management software should provide users with messages on when it’s time to reach out to a client or share breaking news with a population.

Mobile and cloud-deployed case management software should also create a platform to facilitate ongoing conversations with clients, monitor the performance of strategies and equipment, and collect information on medical breakthroughs and changing healthcare regulations. Proper population health management requires solutions that provide immediate answers and facilitate future care activities.

For more information, check out our video on Community Care Coordination

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