The Future of At-Risk Care

Caring for at-risk populationshas never been more important or more complex. Post-acute care providers are under increasing pressure to deliver better outcomes with fewer resources. But amid these challenges, technology is transforming how we approach at-risk care, offering new ways to coordinate services, close care gaps and support clinical teams in delivering the right care at the right time across home-based, hospice and palliative care settings.

In my recent conversation with Devin Woodley, VP, Managed Care and Contracting and B2B Sales, VNS Health, and Charlotte Mather, VP, Hospice Nursing Operations, AccentCare, we explored how post-acute care providers are tackling disconnected data and strained clinical resources.

Disconnected Data and Fragmented Care Coordination

When it comes to managing at-risk populations, data is the foundation. But access to accurate, timely data remains a significant hurdle, especially when it’s scattered across siloed systems or difficult to share with payer partners.

As Devin explained, “It really does come down to data on all fronts. It’s initially, how do you get payers to give you access to their data? That’s an incredibly hard task to accomplish, but you need to dive into the data to see where the opportunity is.”

Even beyond access, the lack of alignment on data baselines can stall progress. “We’ve even lost contracts that weren’t value-based because we didn’t have agreement with the payer on what the baseline was,” Devin noted. “You don’t want to start a contract unless you have agreement on what the baseline is when it comes to the data.”

Charlotte echoed this challenge from her experience in hospice care. “There are disconnects in data sharing between the provider side and the operational side. Just having those connected data points where you’re sharing data and coming alongside with aligned goals. That’s so simple in theory, but incredibly complex in practice.”

Technology is helping providers overcome this. Integrated dashboards and care coordination platforms are giving teams the visibility they need to manage patients across the care continuum. “Technology has been able to really help us and give us insight in an objective way to take the emotions out of the conversation, so we get back to serving the patients and getting the quality outcomes that we all desire,” Charlotte said.

Devin emphasized the importance of both data input and output. “It’s getting data in, but then also getting the data out…to demonstrate what we’ve done, back to the payer. Being able to get that reporting data out of the system is just as important once you get up and running.”

Workforce Strain and Scaling Care Efficiently

Post-acute care providers are under pressure to serve a growing, aging population, but workforce shortages are limiting how much care can be delivered, especially in the field. This is where technology is truly shifting the paradigm.

“We’ve figured out how to leverage technology so we can be much more efficient with the clinical business that we’re driving,” Devin said. “We have population health programs where one RN is generating as much revenue as it would take ten RNs in the home health side. We’re not trying to grow home health or we're not cannibalizing home health at all. It's that we realize to be able to touch and treat more members, that we have to figure out how we can leverage those field clinicians and be more efficient with the work they do.”

Predictive analytics are at the heart of this efficiency. By identifying risk and guiding care transitions, predictive models help clinicians focus their time where it matters most.

Charlotte shared how predictive tools have been a game changer in hospice. They use a solution that provides risk stratification about a patient’s end-of-life journey, helping them deliver the right care at the right time.

The results speak for themselves. Her organization is exceeding national benchmarks in hospice care quality. “Hospice visits in the last day of life, that’s a key metric. The national average is 47.4%, and we’re above 60%. That’s where science and technology in the heart of health care all intersect.”

But adopting technology isn’t always smooth. Clinician trust in analytics can be a hurdle. “When we first rolled out the tool, they didn’t believe it,” Charlotte admitted. “They thought their own intuition was more accurate. Getting the workforce to understand what these new analytic tools are and what they're telling us and how it doesn't take away from what they're doing and what their experience is, was a huge hurdle to overcome.”

Technology as a Catalyst for Better At-Risk Care

At-risk care is inherently complex but with the right technology, providers can turn that complexity into opportunity. Predictive analytics, near real-time dashboards and integrated care coordination tools are helping organizations deliver higher-quality care with greater efficiency, even amid workforce challenges.

The future of at-risk care lies in the ability to harness data, align with payer partners, and empower clinicians with the tools they need to succeed. With the right systems in place, we can improve outcomes, close care gaps, and ultimately serve patients better when they need us the most.

Technology solutions like Netsmart myUnity®, CareManager™ and analytics tools empower providers to align with payer partners, manage risk across populations and deliver more coordinated, high-quality care.