Why Care Management is Critical for Supporting High Risk Patients
High-risk patients tend to suffer from multiple conditions which are also compounded by issues with their social determinants of health (SDOH). Given the situation, these patients are at risk for poor health outcomes, may receive inadequate quality of care, and likely contribute to the highest costs in the healthcare ecosystem. A disciplined strategy for managing the care of high-risk patients can improve health outcomes. The transition towards value-based care requires home health agencies to better control the clinical and financial risk associated with high-risk patients and deploy a care management program.
Understanding the Role of a Communication Platform in Care Management
Care management goals include improving patient health status and reducing the need for expensive medical services. Care management programs apply systems, science, incentives, and information to improve medical practice and help patients manage medical conditions more effectively according to the Health Industry Forum.
McKinsey recently published their insights regarding the ROI of care management programs. Care management programs are unsuccessful if the strategy and touchpoints:
- Do not identify the right people to target
- Fail to reach out to those people successfully
- Cannot engage patients in the ways needed to prompt behavior changes
Digital outreach – such as a using a communication platform to facilitate a cascade of virtual visits and messages – can be used to enhance the episode of care. As McKinsey highlights, these initiatives:
- Expand the methods for delivering care management interventions beyond traditional approaches such as nurse calls and visits
- Help providers identify when and how to target a patient and also maximize the effectiveness and efficiency of delivering the interventions
- Enable the home health organization to “fine-tune” the messaging, timing, frequency and channel (e.g., video, secure messaging, text, email) for the interventions
Digital interventions can also help drive down costs in care management programs. In McKinsey’s experience, companies can achieve a 10-20% decrease in administrative costs by enhancing traditional outreach with virtual care.
How Synzi Can Strengthen a Care Management Program
Synzi’s communication platform can strengthen an agency’s care management program by automating several manual tasks and enabling more effective and efficient interventions. Synzi offers condition-specific messaging to drive adherence (and lower rehospitalizations) amongst high-risk patients. Agency administrators can also use customize the platform to leverage their home health organization’s (or a referral sources’) condition-specific protocol and guidance. Manual tasks such as dialing patients to confirm appointments and check-in with patients can also be automated. Agency administrators can program a series of emails or texts for patients to receive about their upcoming appointments and health care guidance. And, the agency’s specialists and field staff can be more productive by using the platform to conduct virtual visits in place of some traditional in-person visits. Multiple participants can be included in these HIPAA-compliant video calls, ensuring that all care team members are aligned on the patient’s next steps including the patient’s family caregiver. As a result, the home health organization is able to improve the individual experience of care (including quality and satisfaction), improve the health of patient populations, and reduce the per capita cost of care – helping the agency achieve health care’s Triple Aim.