Three Steps to Effectively Manage Your Patient Population

By Tim Gronniger, CEO and President, Caravan Health
Twitter: @CaravanHealth

By the end of the decade, all Medicare beneficiaries are expected to be in accountable care or other total cost of care arrangements, per a CMS Innovation Center whitepaper published earlier this year. The days of traditional fee-for-service – in which providers are paid by volume of services – are coming to an end. Coupled with the extreme stress on health systems from the COVID-19 pandemic, providers have had to find or build population health management systems that make health care transformation manageable.

Providers are transforming care delivery to manage patient costs and care quality through advancing population health. This goes beyond delivering excellent care, it means employing the best tools to provide care, track performance, and make improvements. With the right systems and planning, all patients benefit, including those with the most serious health conditions.

When Caravan Health was founded, providers were adjusting to this new world of value-based payment. No one knew exactly what it would take to thrive in an accountable care organization (ACO), and we built tools and systems one-by-one to monitor performance and drive change in health care.

Below are three strategies for population health success in an accountable care organization, regardless of size or experience with value-based payment.

1. Focus on the Team. A team-based care approach focused on prevention lays the groundwork for population health success. The idea is simple: if every patient has access to preventive care, everyone stays healthier and chronic conditions are under control. This means hiring skilled staff to provide services such as annual wellness visits, chronic care management, and behavioral health integration.

Systems need to easily identify patterns and opportunities at the point of care with a 360-degree view of patients’ health care activities both inside and outside of your organization. ACO providers are financially responsible for total costs of patient care. Keeping tabs on in-network and out-of-network utilization can make the difference between success and failure in value-based payment.

Even better if patients can also set health goals and interact with their care team when they are not in the office. This way, clinicians can monitor high-risk patients, identify gaps in care, and have a holistic view into prevention and wellness initiatives.

2. Track performance. With a team-based care approach in place, ACOs have to track performance on both the quality and financial metrics that lead to shared savings, the financial reward for putting in the work. The most effective systems will integrate claims data, EHR data, and patient generated data, providing a real-time snapshot to let you know that you are on track.

One critical part of the financial picture is risk adjustment to keep track of severity of illness. By capturing hierarchical condition category (HCC) codes, ACOs get credit in their financial benchmark for the level of care they provide. Your technology platform must have a manageable way to bring claims data to the point-of-care to assess system gaps that can be closed. It’s essential not to overlook the importance of an accurate benchmark which determines whether your ACO gets shared savings.

3. Identify and Make Improvements. Assessing gaps in care delivery can improve performance of your ACO. Your system should show which patients are due for an annual wellness visit or other preventive services. Especially during the pandemic, providers need a window in to which patients are living with chronic conditions and would benefit from regular care management visits. These services can be provided safely through virtual means, reducing stress on hospital providers and family caregivers.

Improved performance also depends on teams having access to educational trainings, practice transformation resources, and project plans that deliver best practices as policies, payment, or care delivery standards change. Your team needs to take advantage of the latest thinking and analytics in population health from quality to billing to staffing.

The best plan will drive action through data, engage with patients, improve care for the sickest patients, and make the most of population health revenue streams. Value-based care will soon be the mainstream relationship between care delivery and payment. Providers and patients need systems that can keep up with this new dynamic and manage the increasing flow of information to keep everyone healthier.

Listen to Caravan Health’s Podcast, Health Care by the Numbers.
A podcast that goes where others don’t – discussing the bottom lines of value-based care featuring industry visionaries, innovators, and thought leaders. Health Care by the Numbers is a podcast that uncovers what’s driving health care transformation. Join them for each episode as Caravan Health leaders interview the brightest minds inspiring health care innovation and discuss the numbers which have shaped their thinking. Join the conversation on Twitter at #HCBTNPod.