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04.21.16

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Articles in Category: Population Health Management

Patient-Centered Care Management Crucial for Aging Population Healthcare

Patient-Centered Care Management Crucial for Aging Population Healthcare

I think most of us envision ourselves living until a ripe old age with some discomfort of aging but basically healthy and independent. The fact is, that’s really the exception these days rather than the rule. Why? Because we are living longer and experiencing what I’ll call “reasonable wear and tear” of aging and a much higher rate of chronic illness than ever before. As a result of these factors, it is readily apparent that our current healthcare system and supply of healthcare providers and caregivers will simply be insufficient to take care of our rapidly aging and increasingly chronically ill population in the not too distant future.

Consider these facts. By 2030, just 12 years from now, 20% of out total population will be retirement age or 65. All of us baby boomers will be at least 65. By 2035, the over-65 population will be larger than the under-18 population for the first time in the history of this country. Now that might sound great to those in the business of creating environments and services for that ever-increasing population but, and this is a big but, the traditional model of simply aggregating aging people into common living arrangements and entertaining them until they reach a ripe old age and comfortably transition to the hereafter, just is not going to work any more. Why? Again, because this population is growing sicker and faster than our current healthcare infrastructure and system can handle. Our current healthcare and caregiver system cannot and is not designed to help the aging, chronically ill population make the behavior changes necessary to manage their chronic illness and health and wellness regardless of their living environment. Our current structure is built to just do stuff to people when they have exacerbations of conditions with the idea we can stabilize them until there is another exacerbation and the cycle just continues over and over.

The good news is there is a new keen interest in creating a new approach to managing this aging chronically ill population. We are looking past the old paradigm of creating more hospitals, investing in more machines and doing more and more procedures on the heels of more and more diagnostic tests. This new approach involves frequent personal intervention with patients to guide their behavior towards managing lifestyle behaviors in such a way to optimize their well-being and minimize the impact of their chronic conditions. In so doing, we drive down the costs associated with the traditional healthcare system approach and improve the life of the patient at the same time. Some of this intervention will, no doubt in the future, be driven by technology that allows us to capture real time data. This technology is already available and when coupled with personal intervention becomes a powerful tool in assisting the patient and that patient’s caregivers and healthcare providers. That technology also enables us to access data and provide predictive analytics that benefit current and future patients.

True, patient-centered care management, not costs management, applied to the most vulnerable patient population on a timely basis, is the solution needed now, more than ever, to create a better, more efficient, more responsive healthcare system, while creating positive differences in patient outcomes allowing patients to live healthier, happier, more productive lives.

Organizations, whether they are senior living organizations or more traditional healthcare provider organizations who adopt this patient-centered care management approach, will be far more successful in the future than those that don’t.

NavCare, backed by experienced caregivers and years of healthcare experience, partners with senior living organizations and healthcare provider organizations to deliver comprehensive care management services and technology that deliver better patient engagement and outcomes. The result is higher patient and resident satisfaction with resulting improved revenue for healthcare providers and senior living organizations.

Chronic Care Management for Improved Population Health

Chronic Care Management for Improved Population Health

Coordinating and managing health care services for older adults with two or more chronic diseases for improved population health requires establishing patient self-care and sustaining communication between patients, caregivers, and health care providers. Chronic Care Management (CCM) for population health includes care planning and using population-level measures for better health outcomes. Healthcare organizations that have the ability to obtain, review, and apply analytical data are well on their way to improving patient care coordination. Data analytics help providers to understand the individual and collective health care needs of the populations they serve.

Population Health and Managing Chronically Ill Patients

Population Health and Managing Chronically Ill Patients

Population health management(PHM) encompasses a broad range of care services, from wellness and prevention through disease and complex case management. PHM recognizes that early intervention can help older patients feel better, help those who are at risk stave off the development of chronic conditions, and educate those with chronic illnesses about ways to mitigate complications and decline. PHM is a data and technology driven model for delivering and coordinating appropriate cost-effective care. PHM intervention and care management models optimize physician office practices, ancillary service delivery, and other services to improve patient health and add value.

Transitional Care: A Team Approach for Better Care

Transitional Care: A Team Approach for Better Care

Moving a patient from a hospital to their home or care facility in a community setting is a delicate process. Patients, family members or caregivers can receive confusing recommendations, a laundry list of medications, and conflicting instructions regarding follow-up care. If they are not included in planning or provided with clear “next steps” there can be significant gaps in post-discharge care. As a result, patients will most likely return to the hospital, and often times with more complications than before.

One in five Medicare enrollees is readmitted to the hospital, ED or urgent care within 30 days of discharge, and nearly three-quarters of these readmissions are preventable. Miscommunication, lack of provider accountability, and inadequately prepared or shared care plan leads to ineffective care transition. Consequently, the patient is vulnerable to adverse events. Under the Patient Protection and Affordable Care Act, along with shifts to value-based care and shared risk models, providers and healthcare systems now face financial penalties due to unnecessary readmissions.

Getting the Most from MACRA and Value-Based Payments

Getting the Most from MACRA and Value-Based Payments

Nearly 60 million Americans are covered by Medicare and about 10,000 become eligible for Medicare every day. High-risk beneficiaries and those dealing with multiple and complex chronic diseases are driving cost and quality of care concerns.

Medicare primarily functioned as a fee-for-service (FFS) system where the volume of services delivered, not value, drove payment. This contributed to increased costs with a minimal focus on improving the quality of care. Consequently, the Centers for Medicare & Medicaid Services (CMS) began to look for a different payment system that encouraged incentives for value delivered and that recognized quality of care. The change from fee-for-service to value-based care had already begun in the commercial insurance sector as the large health plans looked to lower costs, spread risk and address quality of care issues.

Achieving Performance and Quality with Chronic Care Management

Achieving Performance and Quality with Chronic Care Management

As the prevalence and associated costs of chronic diseases continue to grow, healthcare stakeholders, including payers, are focusing on performance and population health program (PHM) measures of chronic conditions for reimbursements and value-based incentives

Provider groups taking on risk have initiated disease management (DM) programs for patients with common chronic diseases, and complex case management (CCM) programs for patients who experience critical or traumatic health events, or who have highly complex and high-acuity diagnoses. Core to both DM and CCM programs are requirements for care managers to address behavioral health problems or socioeconomic challenges. Effective care coordination programs have the capability to focus on building relationships with patients and primary care providers. This can allow provider groups and payers the ability to demonstrate improvement in preventive care and quality measures.

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