Team Approach to Patient Care Between Visits

JohnSmithwick-RoundingWell-200Top Three Risks Endangering Patients Between Care Visits and How Care Teams Are Changing Their Approach Combat Them

By John Smithwick, CEO, RoundingWell
Twitter: @RoundingWell

In the past few years, knowing what happens to patients between visits or after acute episodes hasn’t been a priority for provider organizations. As more and more reimbursements are tied to quality measures and outcomes, organizations are finding it vital to know the health status of their populations so they can spot problems earlier and intervene sooner to prevent the need for costly procedures.

The ability for organizations to provide proactive care for populations depends on care teams having real-time access to patient data. Care management and patient engagement platforms are able to collect patient-generated data and EHR data and make the both actionable. Along with other platforms uncovering insights into population health, RoundingWell recently shared data collected directly from patients over the past year at organizations spread across seven states with a diverse mix of patient populations, including nephrology, cardiology, oncology and orthopedics. The data looks at top risks for chronic and post-acute patients to give care teams a path for shifting care practices. The top three risks endangering patients were:

  1. Blood pressure management
    The current fee-for-service model often bypasses preventative care between patient care visits. Because of this, it may be up to six months before intervention after a patient’s health status changes. This delayed reaction leaves patients without the remedial blood pressure management care they need, putting them at risk of hypertensive and hypotensive episodes.
  2. Medication therapy management (MTM)
    Current EHR systems call for manual interpretation of patient data from care teams, making the process complicated and incomprehensive. Because of the multiple dimensions of complex diseases, this leaves providers with time consuming care plans. And, although its effects are recognized as beneficial, many patients miss out on the advantages of MTM. This is because of the absence of symptom planning, comprehensive medication review and guidance for medication use.
  3. Care plan adherence
    Patients who have questions about — or may even initially leave the care giver’s office without ever understanding — their care plan are often left without guidance for long periods of time, which makes it difficult for them to follow the plan completely. This is because of the shortage of resources provided to them and the reliance on caregivers to manually communicate with patients who need answers.

The migration to value-based care is pushing providers to spot individual patient risks between visits, as well as population-level risks. This makes it necessary to change how care is delivered. Some new ways care teams are doing this are through:

  1. Proactive interventions
    Patients typically follow a bi-annual appointment schedule and can go the entire time between visits without updating providers of their health status. For chronic patients, this is a huge issue because of their frequent changes in health. Proactive care team interventions help mitigate this issue by initiating provider/patient communication between scheduled appointments.
  2. Asynchronous communication
    While providers have been expected to make thousands of manual phone calls regarding their patients’ health status in the past, asynchronous communication improves efficiency by allowing care teams to communicate with patients in a fraction of the time. And not only will this procedure cut down on the extra time that care teams are using up instead of being in the care field, it lets them directly message patients to establish trusting doctor/patient relationships.
  3. Standardized care protocols
    With many patients at risk for the same issues, care teams need a shortcut that helps avoid unneeded, time-consuming care planning. Instituting standardized care protocols for these risk areas lets care teams work off a pre-established care plan, simply tweaking small bits to fit the individual patient and saving loads of time.

These changes let providers become more proactive about patient care plans to help address risks and avoid costs associated with value-based payment models. By incentivizing proactive patient care, value-based payment models encourage the evolution of care and development of technology that makes data actionable.