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 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.
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.
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.
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.