Written by Care management is an invaluable tool to identify priority populations and address their biopsychosocial needs. In reality, most care management programs don’t show a meaningful impact on health and cost outcomes. One of the reasons for this suboptimal ROI is the lack of timely data about the patient. Patient healthcare data is typically spread across dozens of disparate systems or data islands that don’t communicate with each other. Clinical results, labs, imaging, admission, discharges or transfer information is often not shared in a timely manner with the care management staff. The problem is only getting exacerbated with new data streams coming from connected devices, virtual care providers, and SDoH data sources. The inability to effectively integrate healthcare data creates a tremendous amount of inefficiency leading to overworked teams, shrinking margins, and poor health outcomes.
The patient longitudinal record is a single unified patient record composed of data from numerous data sources across the healthcare continuum. Patient longitudinal data can provide a real-world picture of your patient journeys, treatment pathways, and health outcomes. It is the foundation of value-based healthcare and critical for improving the ROI of your care management programs.
With the universal patient record, you get a trusted 360-degree view of the people you serve to accelerate the success of your care management initiatives and fully understand your patients’ preferences, risks, and needs from the beginning and throughout their care journey.
Additionally, it helps in the following areas:
Improved targeting of multiple high sources of value
The traditional care management programs are designed around managing a condition, such as diabetes, or preventing an acute event, such as a readmission. This narrow approach often leaves out significant sources of value to reduce costs and improve the patient experience. With advanced analytics built on the comprehensive and integrated data, care management teams can explore these additional sources of value such as reduction of inappropriate procedures, optimized site-of-care choices, closure of care gaps, improved CAHPS performance, and clinically appropriate use of medication, imaging, and pathology.
Improved decision making
Most patients enrolled in the care management programs have multiple chronic conditions such as diabetes, asthma, CHF, COPD, etc. Since the universal patient longitudinal record incorporates information from over time and across systems, it provides a holistic view of a patient’s medical history to deliver whole-person care. In addition, a complete and trusted, 360° view of data about each patient can inform your care management staff’s decision-making in a range of crucial areas from resource planning, pathway design, and interventions for complex care management. Further, it enables care management teams to closely monitor the progression of these long-lasting conditions and adjust the form of care.
Improved care coordination
The coordination of care across the healthcare continuum can be very challenging. When data is unavailable it can have a negative impact on healthcare costs as well as patient care. The universal patient longitudinal record can help bridge the data gap from one patient’s visit to the next. It provides a comprehensive collection of clinical results and other relevant health information, such as allergies, diagnoses, lab and imaging results, and ED visits to the care team. The longitudinal data also helps in ranking providers by cost and quality metrics. This scorecard can be used to build an ecosystem of high-quality providers that you can use to refer your patients.
Accurate ROI measurement
Most care management programs are not able to accurately measure the ROI of their care management efforts. This is because they lack accurate utilization data. The longitudinal patient record provides one of the most effective observational data sources by combining multiple data sources such as claims, medications, labs, imaging, clinical summaries, and SDoH data to help you evaluate the real-world impact of your care management programs.
Sprite Health integrated care management solution is built on a modern data platform that aggregates data from multiple sources (including EHRs, labs, and imaging) to create a longitudinal patient record. The FHIR-enabled data platform creates a universal patient record that tracks an individual’s health, risk factors, care usage (along with associated costs), and outcomes over time. This enables your care teams to have the information they need to provide better care and support.