It may be hard to believe, but the United States has one of the poorest health outcomes among first-world countries. This is surprising to due to healthcare’s high spending in our country, which currently totals $2.5 trillion a year – the most per capita in the world. Sadly, the high spend does not result in better care.
Care management software sits critically in between patient, community, and health system. Research and evidence are pointing to the importance of putting patients at the center of this reform if we ever hope to improve outcomes and control costs.
Healthcare outcomes can have many influencers. The quality of the care delivered, including the consideration of evidence rather than intuition, the accessibility of care, and the affordability of care are just a few. Most importantly is the patient, and the countless behavioral, environmental, and psychosocial factors that make each of the patients distinctively unique.
Hypotheses now overwhelmingly point toward the fact that patient-centered, evidence-based care is fundamental to health reform. Nevertheless, consistently defining, and more significantly, putting the concept to action in daily care delivery is challenging. The “one-size-fits-all” approach towards patient behavior modification has previously been unproductive, and is the exact opposite of the widely-known term “patient-centered care.”
The World Health Organization (WHO) reports that approximately 70 percent of health outcomes are related to the aforementioned factors and that, until we can effect, understand, and change behavior based on modification of these factors, our costly healthcare efforts will continue to be substandard. In order to grasp accountability for healthcare outcomes, understanding the patient’s part (or lack thereof) in achieving evidence-based practice is crucial.
Changing behavior is not easy. This difficulty is only increased by the time constraints faced in the current care delivery system. To effectively evaluate and adjust behavior, health systems will have to find mechanisms to identify, stratify, engage, modify, and measure a patient’s individual characteristics and ensuing behavior as related to health outcomes — all, of course, while being comprehensive and cost-efficient.
A trusted method in achieving this with care coordination is through coordination supported by software specifically designated for the tough task. Coordinated care has reliably been a milestone in bringing about a successful and caring health system, yet quality assessment in this field needs improvement in delivering actionable, outcome-focused measures.
The accelerated movement to outcomes-based reimbursement has pushed health care systems to fully understand how to manage an individual patient’s health and healthcare across the care continuum in order to be successful. That means that engaging the patient as an active, accountable participant in the process is crucial.
A strong care plan, which serves as a guide during the involved and complicated process, should incorporate a person’s medical and psychosocial needs, evidence-based interventions to address those needs, and the patient’s individual values about receiving treatment. It spells out the process designed to meet those goals, and holds those accountable while doing so.
Successful care coordination platforms assess a patient’s inclination to change, monitoring and measuring a patient’s response to evidence-based treatment, and identifying in real time where break-downs occur. By giving all members of a care team access to this information, a harmonized and systematized delivery of evidence-based, patient-centered care is attainable — and even likely.
Care coordination software solutions are the feasible answer to operationalized, evidence-based care. Coordinated care captures not only treatment plans initiated, but the individual patient preference, modifications to accommodate for both factors, and move toward mutually established goals.
With the end goal driving improvement in health and healthcare, care coordination gives providers the ability to convert evidence into action, evaluate the practice and adjust on an individual basis to achieve a defined outcome.
Kristin Stitt is an Advanced Practice Nurse with experience in analytics, system management, implementation science, predictive modeling, and care coordination. After working as an analyst in the airline industry, she migrated to healthcare, serving in a variety of roles in private practice and an integrated ACO, as well as private industry. She recently completed a Doctorate of Nursing Practice in Systems Management at Vanderbilt University, focusing on the utilization of system data and clinical evidence to concurrently guide administrative and clinical decision making in ACO population health initiatives.