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.
Strong patient relationships are important for better health and quality of care. Quality-based compensation has continued to evolve with quality-based care and performance metrics. Practices and health systems have aimed to find the balance between clinicians seeking to improve patient health and eliminating cost drivers, as well as risks. Population health management (PHM) can too often focus on measuring quality in terms of task-based care. In some instances, this can significantly diminish the clinicians’ ability to decipher difficult medical situations and impact their ability to build strong relationships patients who have complex chronic care needs.