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.
Engaged patients, famillies and caregivers can help lower medical costs, reduce hospital admissions, and improve health behaviors. The patients' health has a greater chance for improving when the family and caregivers can better communicate the importance of incorporating a healthier diet, increasing levels of physical activity, and medication compliance for chronic diseases management. However, recent data on health care consumers found that 1 in 3 patients are disengaged in their own care. Meaning that patients did not have a clear understanding of their diagnosis and conditions, and they weren’t actively working towards better self-management and care.