Population Health Management isn’t a concept that is new to the healthcare industry however, efficiently managing high-cost and high-risk patients is becoming a necessity with payment models focusing on reducing cost and improving outcomes. With this, many organizations are instituting an increased focus towards population health management, participating as Accountable Care Organizations (ACOs) in order to more effectively identify, understand, engage, and track patient populations. An ACO delivering high-quality and low cost care will share in the savings that is achieved for the Medicare program.
Many EHR vendors, including Epic, are looking to provide tools to assist organizations in moving toward better and more coordinated care for individuals, greater health and disease prevention, and less healthcare expenditure. Healthy Planet is Epic’s solution for helping organizations achieve these goals. It allows clinicians to identify and address gaps in care with patient populations using tools within Epic – EpicCare Ambulatory, MyChart and Cogito – to take action on population health analytics, integrate care management and coordination, and engage the patient in their care.
Many of our clients are part of an Accountable Care Organization (ACO) establishing integrated care teams made up of physicians, nurses and social workers that utilize the tools provided by Healthy Planet such as navigators, dashboards and bulk ordering and communication functions as well as MyChart to help manage the needs of their high-risk patients. Healthy Planet’s ACO functionality has been used to define ACO patient populations, complete patient questionnaires for risk stratification, track patient outreach, provide care management which includes documentation of medication compliance, care plans and goals, as well as interaction through MyChart. Organizations have also begun to create team Longitudinal Plans of Care allowing other clinicians throughout their organization as well as other Epic organizations to see their care efforts in one concise place.
As a result, organizations have already begun to see the benefits of their Population Health Management efforts meeting the goals of:
- Accurately and efficiently capture data for preventive care and disease management services
- Monitor the performance of providers on closing care gaps for these services
- Implement chronic care management workflows for care managers
- Apply risk stratification models to your patient populations
- Increase efficiency through bulk ordering and communication
- Engage patients through MyChart
- Improve transitions of care and patient engagement with a longitudinal plan of care
Through their care management teams, they have been able to better understand patient needs in areas ranging from transportation to doctor’s appointments and picking up medications to education regarding their clinical care. Reporting shows decreases in Emergency Room visits as a specific example and clients continue to gather data that demonstrates how critical care management is to overall population health. The successful implementation of tools such as Healthy Planet provide both short term and long term benefits that result in a more educated ACO and an overall improvement in the healthcare experience and general well-being of individual patients.