Wednesday, July 21 | EHR Solutions and Operations, Thought Leadership, Human Services, Post-Acute Care

Caring for Chronic Conditions? Two Ways Population Health Management Solutions Can Drive Success

By Julie Hiett, VP and General Manager, Bells AI

With the increasing prevalence of shared-risk payment models, providers for patients with chronic conditions are dealing with ongoing changes to the way they are measured and reimbursed for services.

As providers take on more and more risk in new models of care, it is critical to have a full view of specific risks for each patient, particularly for providers managing chronic conditions. Population health management software can help organizations efficiently use their data to drive the optimal care plan for each patient, improving outcomes and reducing the cost of care. 

Just as the electronic health record (EHR) is the core technology enabling providers to document care, a strong data-driven, population health management solution is the key to aggregating patient data from across the care continuum. Organizations can use population health management solutions to stratify risk across their population and create a care plan for each patient that delivers the right care at the right time at the right venue.

Here are two ways population health management solutions can drive success at your organization.  

1. Improve care quality

Population health management technology can do more than stratify patients by risk to identify the most appropriate course of action. It can help staff more efficiently manage care for each patient by automating staff and task assignments. When a patient has a potential gap in care or requires an intervention, this type of technology can immediately assign an intervention and follow up. For example, staff can be assigned to immediately follow up with patients who miss their follow-up visit with a physician after being discharged from a hospital. Care managers can receive alerts whenever patients present at an Emergency Department (ED), enabling immediate follow-up. Efficiently managing care through technology enables better adherence to care plans and ultimately better care for patients.


2. Reduce cost of care


Patients with chronic conditions are often at increased risks for hospital readmissions and ED visits. These are not just potential indicators of a gap in care, but also costly, particularly in a shared-risk model.


By using a population health management technology solution, organizations can aggregate data on their patients from their own EHR as well as the rest of the healthcare continuum. That data can be used to stratify risks for each patient and set the best care plan for each patient. Providers can manage the risks to each patient by delivering the right care at the right time at the right venue, reducing preventable ED visits and hospital readmissions thereby reducing costly episodes of care.

 

As a provider of care for patients with chronic conditions, you deliver care to the most vulnerable members of our communities. A population health solution can complement your EHR and put your data to work, enabling improved care quality and cost of care.

To learn more about our population health management platform today! 

Navy Veteran Ronnell Spears started his 29-year career in home care in 1992. He earned a BA in Accounting at the University of Cincinnati as well as his MBA at Indiana Wesleyan University. For the first 20 years of his career, Spears owned and operated a family-owned business called Caring Hearts Home Health Care. In 2011, he sold the business to Home Care by Black Stone. Post acquisition, Spears joined the executive team to assist the company in various ways such as new EMR selection, overseeing revenue cycle, sales director and operational oversight. He remained at Black Stone through two acquisitions, last of which was LHC Group Company. Before joining the Netsmart team in January 2021, Spears served as Area Executive Director for Western Ohio at LHC, where he earned the 2019 Servant Leadership award.
 

 

Meet the Author

Julie Hiett · VP and General Manager, Bells AI

From the CareThreads Blog

The Three Pillars of a Sustainable Healthcare Revenue Cycle

The Three Pillars of a Sustainable Healthcare Revenue Cycle

Thursday, June 04 | Post-Acute Care,Thought Leadership

For many healthcare leaders "billing" is viewed as a back-office function. It is often treated as the final step to resolve issues that began weeks or even months earlier. In today's complex regulatory and reimbursement environment, this approach is no longer sustainable. Treating the revenue cycle as a siloed endpoint can lead to increased denials, delayed cash flow and staff burnout.

Read the blog
Why Rising Acuity is Exposing the Limits of Fragmented Systems

Why Rising Acuity Is Exposing the Limits of Fragmented Systems

Wednesday, May 27 | Post-Acute Care,Care Coordination,Thought Leadership

Something fundamental has shifted in senior living, and most organizations feel it every day. Residents are delaying move-in and ultimately arriving with more complex needs than many communities were designed to support. Residents and their families still want exceptional hospitality and services. Referring providers and partners expect clinical coordination while payers demand outcomes supported by data. And operators are expected to deliver all three at the same time and at scale.

Read the blog
From Cleanup to Clean Claims: Rethinking Eligibility in Post-Acute Care

From Cleanup to Clean Claims: Rethinking Eligibility in Post-Acute Care

Thursday, May 21 | Post-Acute Care,Thought Leadership

Eligibility in post-acute care has become a complex and financially impactful challenge in the revenue cycle. What started as a once-a-year administrative task is now a continuous operational pressure point. Yet many organizations are still treating eligibility as something to clean up after issues arise. That approach is becoming difficult to maintain as payer requirements shift, patient coverage changes more frequently and teams are stretched thin. The result isn’t just inefficiency. It’s real financial risk.

Read the blog