Coordinated Care Across a Population

One of the primary challenges of any population health approach is the coordinated care of conditions across a population.

Goals of Coordinated Care

  • Reduce fragmentation in care delivery by organizing care across healthcare providers and settings
  • Better manage care transitions as patients move through the network
  • Close gaps in care
  • Decrease hospital readmissions by identifying problems before they require an inpatient stay
  • Manage referrals to help keep patients within the network
  • Keep patients out of the emergency room

A Coordinated Care Approach

  1. Connect
    Build a foundation of clinical and financial connectivity by bringing together disparate systems to build a complete view of the patient. Health Information Exchange technologies like RelayHealth Enterprise HIE, can help build longitudinal patient records accessible at the point of care.
  2. Identify
    Using a population health registry tool such as McKesson Population Manager™, a general population of patients is stratified into smaller, more specific populations. For example, members of a stratified population may include patients with heart failure that are not taking the appropriate, evidence-based medications.
  3. Engage
    Patient engagement is a key success factor in coordinated care. Using an evidence-based care plan, patients are taught to understand their condition and the steps they should take to help manage it. Additionally, as provider organizations manage populations, they must address maintaining wellness in all segments of the population in addition to the patients that are driving most of the cost. Healthy patients that do not need intensive care management or care coordination must also be factored into the network's broader patient engagement model, as keeping these patients healthy is of paramount importance
  4. Enroll
    Once a patient has been identified and mentored, he or she is enrolled into the coordinated care program if appropriate. The level of engagement is dependent upon the patient's clinical acuity and the content of the care plan. It may include phone calls, virtual encounters, or face-to-face interaction
  5. Monitor
    Ongoing monitoring is necessary to make sure the patient is staying compliant with his or her care plan. Ideally, care management is provided at scale by automating data gathering and surveillance, care plan generation, escalations, KPIs, and dashboards with role-based visualization and workflows. McKesson Care Manager™ can streamline the process of managing and tracking care plan compliance
  6. Escalate
    When a new care need is identified, the patient's profile should immediately be flagged and escalated for new treatment to prevent an eventual emergency room visit or hospital stay. The goal is to continuously manage the population at the lowest effective level of intensity of care management and provider interaction, while preventing escalations in care

Learn how care management software can help your organization coordinate care delivery for your most challenging patient populations.

Next: Creating a patient engagement strategy