Helping patients help themselves with Digital Care Management

Let’s start with what the term ‘Care Management’ stands for.

Essentially, it is a set of activities intended to improve patient care and reduce the need for medical services. The intent is to help patients and caregivers manage health conditions effectively. Care Management programs make use of systems, science, incentives and information to improve medical practices to assist consumers and their support systems. The purpose is to engage in a collaborative process designed to better manage medical / social / mental health conditions.

All of this sounds promising. However, we have to understand the need for Care Management as a discipline. The following enumeration helps us answer the ‘why’:

• Improve patients’ functional health status
• Enhance coordination of care
• Eliminate duplication of services
• Reduce need for expensive medical services
• Increase patient engagement in self-care

Now we shall look at the three components that Care Management comprises of, which are:

• Identification
• Stratification
• Prioritization

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The idea is to carry out all three to identify consumers facing the highest risk and those who offer the greatest potential for improvements in health outcomes. Incorporating clinical and non-clinical sources of information help to identify consumers who will most benefit from Care Management.

The tools / strategies used in Care Management include:

• Health risk assessments
• Predictive models (algorithm-driven models that use multiple inputs to predict high-risk opportunities for Care Management)
• Surveys (eg: patient health questionnaire)
• Case finding (eg: chart reviews, surveys)
• Referrals (from members, providers, communities)

Intervention

An intervention is meant to meet individual consumer needs, and respect the role of the consumer (patient) to be a decision maker in the care planning process. Interventions should be designed to be multifaceted to best serve consumers. They should be tailored to improve quality and cost effectiveness, and ensure coordination of care.

The tools / strategies involved include:

• Evidence-based practices
• Interactive care plan (developed based on consumer-set priorities)
• Multidisciplinary care teams
• ‘Go to’ person
• Medical home
• Physical / behavioral health integration
• Specialized patient engagement (eg: self-management training)

Digital platforms

Adopting new technology providers and payers fosters proactivity in the healthcare delivery process. For example, leveraging Big Data, predictive analytics and multichannel reach to identify top spenders based on activity and clinical data addresses gaps in care and anomalies in patient behavior.

These digital platforms aim to:

• Reduce medical errors
• Increase care quality
• Improve financial results
• Optimize costs
• Meet government regulations
• Improve patient experience(s)
• Meet consumer expectations
• Satisfy compliance mandates
• Ensure privacy and security

Healthcare digitization helps in patient enablement through multichannel infrastructure, while integration with personal medical devices enables self-Care Management and monitoring.

Patient enablement is possible through Information, Intelligence and Interaction. Let’s discuss these three one by one in some detail.

Information

Data flows in from various sources like electronic health records, medical devices, social media, reimbursements, and lab records. This data is optimized and arranged such that it can be first read intelligently by the system, and then analyzed.

Intelligence

A patient’s behavior can be analyzed by studying his / her data and observing him / her. This analysis can help predict events like rehospitalization, preventable hospitalization, medical intake and therapy adherence. The approach can be used to focus on high-risk and high medical spend patients, health risks and better optimization of costs to provide effective and affordable care services.

Interaction

Various touch points of the patient journey such as health education, medication, diet therapy, psychological intervention and exercises are effectively monitored real time with the help of digital networks and IoT for better patient care provision. In fact, the health conditions of patients are assessed before bringing them on board.

In conclusion …

Digital Care Management provides a powerful platform to meet the demands of an information-driven healthcare environment. It integrates medical devices and diagnostic tools to help patients monitor and manage real-time medical information about themselves. The result, and intent, is to accurately measure the impact of patient services and quantify them.

ValueLabs’ Digital Care Management Solution exemplifies this lucidly. An analytics-based platform, it enables a longitudinal view of patient data while accurately measuring the effect of various patient services through the following:

• Care Exchange – A comprehensive data lake that can assimilate multitude of data sets
• Care Insights – Deciphers the elements of harmonized data to provide a holistic patient view through analytics
• Care Connect – Enables touch points across the patient life cycle, catering to both efficiencies and experience

Suffice to say that while patient population data can help take preventive action and assist in taking control of patients’ behaviors, ValueLabs’ Digital Care Management Solution can help achieve cost, quality and patient experience objectives that much better.