Category Archives: Patient Engagement

Engaging High Risk Patients through Care Management (Part 2)


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

In part one of this post on engaging high-risk patients through care management, I discussed how different patient segments require different levels of care management relationships and tools. For the highest risk patients, a patient engagement strategy is centered on high intensity care management. Next, let’s look at how technology can help care management have a greater impact on outcomes for the highest risk segment.

Coordinating Care Across a Multi-Disciplinary Team

The care for a high risk patient can involve a large team including multiple specialists, pharmacists, care managers, office assistants, community health organizations and family members or friends. Coordinating activities among a diverse team requires shared access to a longitudinal patient record that gives a comprehensive “360 degree view” of the patient. The 360 degree view includes information such as:

  • Claims data (e.g. services obtained, medications, etc)
  • Dynamic care plans
  • Lab results
  • Medications
  • Patient outreach information
  • Patient supplied information (biometrics, logs/journals, preferences, etc.)
  • Predictive analytics such as a readmissions risk score, clinical risk, forecasted cost, etc.
  • Barriers to care
  • Gaps in care/quality measures that need to be closed
  • Important non-clinical information (e.g. patient motivation, family support team members, life events such as a recently deceased spouse, and other social factors)

With this enriched view of the patient, care team members across the continuum can work more efficiently together closing gaps in knowledge and communication while operating at the top of their license. This can result in reduced redundancy in assessments, surveys and tests. Today, enterprise population health technology can bring together and make available all of this information in a shared workspace even if the information is stored in disparate IT systems.

Incorporating a patient-centered approach

A deeper understanding of patients helps drive a patient-centered approach, which is critical for patient engagement. For example, if a patient is motivated to achieve a certain goal such as travel to her daughter’s wedding, then every member of the care team can reinforce her motivation and encourage the patient and engage them in the plan of care. If every care team member has access to all patient information, then patients won’t have to repeat the same information to different care team members and patients begin to sense coordination among providers. If there is a family member, friend or community organization that plays a key role in the patient receiving care, then that critical piece of info will be incorporated into the assigning of tasks. The end result is a personalized plan of care. If patients see that the entire team “knows” them, it improves the overall patient experience, builds trust and can improve engagement.

Optimizing time with patients

Care managers are often challenged by a high volume of daily manual tasks. For example, in order to assess a patient and complete a care plan, care managers must track down and synthesize information from multiple systems and offline sources. With a full case load, efficiency is a challenge that ultimately impacts the amount of time care managers can spend focused on patients. Technology can help care managers spend more time with patients by automating time-consuming tasks. For example:

  • Care plans, task lists and interventions can be automatically generated and updated from assessment responses
  • Complete medication histories can display order history and fill history to enable faster review and support compliance review
  • Patient workloads or specific tasks can be reassigned to other care managers or support staff, assuring “top of license” activity
  • High risk patients can be tracked across the continuum through event-based alerts (e.g. admissions, discharges or blue tooth device alerts).

To summarize the main takeaway from both posts, patient engagement and care management strategies are closely linked and should be tailored by segment. As part of population health initiatives where the focus is often on high-risk patients, patient engagement strategies should be on a one-to-one basis, and linked to relationship building through high-intensity care management. New population health technology has emerged to help coordinate care for the highest risk patients. As more providers make the shift to value-based care and seek efficiencies to help them scale programs, I believe that technology will play a central role in helping the highest risk patients. If you’d like to discuss your care management strategies in more detail then send us a note here.

Engaging High Risk Patients through Care Management (Part 1)


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

One of the most challenging issues in healthcare today involves “patient engagement”. It is defined by the Center for Advancing Health as “Actions individuals must take to obtain the greatest benefit from the health care services available to them”. The importance of patient engagement is undeniable. Patients active in the participation of their own care have a greater likelihood of achieving successful outcomes. How providers should approach patient engagement for different patient segments is still an evolving science. Patient engagement requires different levels of care management relationships and tools for different segments. In this two-part blog post, I am going to focus on the highest risk segment, and will address lower risk segments at another time.

Population health management is a large undertaking, requiring a variety of approaches to assure broad impact. The figure below shows an example of patient segmentation along with the types of care management relationships and tools appropriate for each segment. At the top of the pyramid is the highest 5 percent in terms of risk. In the middle are the 30 percent of patients with rising risk. The base of the pyramid is the 65 percent identified as having low risk. Let’s examine the segments more closely to see how patient engagement and care management strategies can vary between the segments.

CM Pyramid

 

High Risk

The top 5 percent of patients require high-intensity, 1 to 1 care management involving a multi-disciplinary team. Patients may have comorbidities that require more complex coordination across the continuum of care. Due to the high clinical risk for this group of patients, a care manager needs to play a lead role within the care team, guiding patients to take the actions needed to obtain the greatest benefit from the health care services available to them. Therefore, a patient engagement strategy for high-risk patients is really centered on high-intensity care management providing direction to the appropriate level of care and education about symptom monitoring and action plans.

Rising Risk

In general, the rising risk segment requires moderate intensity care management services, referred to as condition management in the diagram. These patients can pose an escalation risk if unmanaged, so the emphasis is on providing a consistent set of evidence-based care or education about self-management of a newly diagnosed condition. Patient engagement for medium risk patients is often a combination of consistent patient outreach and communication along with tools to encourage self-management. Within this group, there can be a subset of patients identified as “movers”, patients whose level of clinical risk is predicted to increase over the next 12 months. Higher intensity care management can be appropriate for “movers” in order to proactively address their conditions before they become more acute.

Low Risk

The low risk segment is the largest group, nearly two-thirds of the population. The focus for this segment is on preventive health and wellness to provide age and gender appropriate recommendations for care. Wellness tools including patient education and coaching may center around lifestyle choices and illness prevention based on health risk assessment data. Due to the size of this segment, low-risk patients must take on more of the responsibility for self-care. They are the ideal segment to benefit from patient engagement and outreach tools such as an interactive portal and patient reminders.

In the second part of this post that will be published next week, I will go deeper into technology designed to achieve effective high-intensity care management.

The Future of Healthcare – Patient Engagement is Due for a Paradigm Shift


Post by Scott McLeod


Director of Product Marketing, Caradigm

Just as healthcare is making the shift from volume to value, the concept of Patient Engagement needs to be reimagined in several important ways:

View patients as healthcare consumers with varying levels of engagement in their own care…
Some patients will actively choose how, where and when to access healthcare based on cost, quality data and other patient’s reviews. They expect personalization and patient-centricity from their healthcare providers, and make decisions based on being directly responsible for healthcare costs.

Other patients may feel overwhelmed by managing their health and will require a more guided and supportive approach to understanding, monitoring and potentially confidently managing their conditions at some point.

Acknowledge the impact of factors such as behavioral economics in decision-making…

The reality is people often don’t make rational decisions – in fact, many irrational factors influence thinking such as:

  • Status Quo bias: “This is what I’ve always done…”
  • Complexity Aversion bias: “Too many factors to consider…”
  • Present Time bias: “Going to the gym now is too hard…”
  • Peanuts effect: “It was only 1 donut a day (for 10 years)…”

Important health-related behavior changes need to be framed for patients in recognition of these biases – the long-term impacts of old habits can be re-framed relative to current goals, incentives can be created to establish more immediate payoffs for difficult changes and seemingly overwhelming tasks can be broken into a series of smaller, achievable wins that build confidence and belief that “Yes, I can do this.”

Health goals and behavior changes must be made relevant to each patient by relating them to individual, personal priorities:
For behavior change to occur, care has to fit meaningfully into patient’s lives. Patients are motivated more by personal goals rather than potentially overwhelming healthcare metrics. Patients care more about spending time with their grandkids or being able to walk their dog rather than controlling blood glucose levels or lowering blood pressure. By understanding these priorities and reaching patients with relevant, personalized messages at the right time outside of the care setting, the likelihood of successfully triggering positive health-related behaviors increases dramatically.

For success in population health management to be achieved, Patient Engagement must evolve from being a non-essential, ‘nice to have’ function to a critical driver of success. By clearly demonstrating the value and ROI that patient engagement can bring to the management of populations, the role that patients play will finally be recognized – for the impact it can have in their own success and that of care teams. When patients are truly activated to participate in their own care and own the management of their health, the industry will be transformed.