The patient as part of a larger cohort – coordinating population flow

 From a strategic perspective, we can think of care coordination on two levels – that of the whole population of people and that of each individual patient.

At the population level, we refer to moving all the patients of a targeted condition or situation through the healthcare system in the most efficient and coordinated way. Coordinating the ‘traffic flow’ of patients through the healthcare system adds value by the use of only best practices and processes consistently across that entire population.

One example is whole-population screening. The checks that, for example, all women within a defined age range should have at specific times across their lifespan, which include cervical smear tests, mammograms, and so on, as examples of uniform best practices for an entire population of women. The software ensures every relevant impacted woman in that population has the necessary checks.

An example from New Zealand is the National Child Health Information Platform (NCHIP), which monitors and guides the essential care steps for all children in the country. Another example is the National Diabetes Disease Management Programme in Northern Ireland, which ensures that all patients with diabetes in Northern Ireland (around 100,000 people) have all the fundamental guideline recommended care at the right time with the right provider for each care step.

This level of care coordination should incorporate the appropriate targeting of patients based on those most likely to benefit from any care to be provided. The analytics should capture the women who have missed their regular mammogram, or other similar reasons for gaps in care, or children who are not meeting growth milestones, or diabetic patients with abnormally high HB A1c, for instance. These examples highlight that the underlying software needs to be flexible to handle a wide range of use cases when tackling the health of an entire population.

Coordinating clinician workflow around each individual patient

At the individual patient level, we can dig deeper into the processes of care and provide information and planning to apply integrated care plans that are both consistent with the local best practice guidelines and individualised to meet the specific needs of each patient.

Components include: a standardised care plan with the ability for clinicians to make any appropriate modifications to suit the unique needs of each patient; a complete circle of care indicating who are all the involved providers and organisations in a patient’s care team; and ability to securely message any member of the circle of care.

Not to be forgotten, of course, is the need to involve patients more meaningfully in their care and, in many circumstances, their caregivers too. Hence the value from an integrated patient portal with ability for patients to enter, generate or capture data that’s relevant from their perspective.

Reducing overtreatment or low-value care

These concepts also guide healthcare providers to reduce overtreatment or low-value care, including unnecessary medications, tests, and procedures. The approach should be one of ‘making the right thing the easy thing to do.’  Reducing unnecessary treatment increases cost efficiency of the entire healthcare system and is a major goal of any population health initiative.

Interested in learning how Orion Health can help to improve care coordination and reduce wasteful care?