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Patients’ health outcomes can be affected by a range of factors such as whether they have stable housing, access to food, transport, employment, and support.
Using social determinants of health analytics software can help healthcare organisations understand the link between non-clinical factors and patient reported data. This can help your care team understand any barriers to care that wouldn’t be identified by medical records. Having a deeper understanding will help you identify those requiring extra support.
By using this data within your Medicare population and ACOs you can gain a greater understanding of how to engage patients by using their social risk data to help target outreach, follow-ups and preventative care.
Understanding Social Risk Through Patient Reported Data
Medical records can tell you why a patient has been diagnosed with a particular condition and what treatment they have received. But they won’t tell you why they are struggling to follow their care plan. They may struggle to attend appointments due to a lack of transport or delay taking their medication due to having to prioritise paying household bills.
Health analytics software can help you understand this by providing data relating to housing, employment, income, food security, transport and community support. This can give you a greater understanding of the barriers they may be facing. Patient reported data can be invaluable as their situation can change.
They may have had good transport previously but due to changing jobs or moving home they now struggle to access care. Using regularly updated data will help your care team identify any new needs they have.
Improving Engagement With Medicare Patients
To engage with patients you need to communicate in a way that meets their individual needs. Older patients may struggle with transport, money, loneliness and managing multiple providers.
Using Medicare patient engagement software can help organise outreach by helping your team identify those requiring follow-ups and understand any barriers to care. Having patient reported data means your outreach will be more relevant.
Care should be communicated in a way that is easy to understand. Consider how they like to be contacted, if they require communication in a particular language, if they need support from a carer and how complex the information is. Explaining why they need to be followed up can help them understand.
Closing Care Gaps Within Accountable Care Organisations
Accountable care organisations aim to provide joined up care, improve quality and manage population health. However, simply knowing that they haven’t had a screening or attended an appointment does not tell you why or how to help them.
Using care gap closure software for ACOs can help organise follow ups, understand any outstanding needs and help you prioritise those requiring extra support. By combining clinical data with relevant social data you can target your outreach.
For example, if a patient is frequently missing their preventative appointments they may need support with transport. Knowing why they are missing out means your care coordinators can choose a more relevant intervention and understand if they have received the service they need.
Improving Referrals To Community Services
Referrals to community services will be most beneficial if they can actually access the service. Simply referring them to a food bank or transport provider does not guarantee they will receive any help.
Using a closed loop process will help you understand if they have been accepted by the organisation, contacted, had an intake appointment and received the service. It should also highlight if they have been referred but couldn’t be contacted, declined or weren’t eligible. This will help your healthcare team understand when to follow them up, find an alternative resource or reassess their needs.
Research and guidance around referrals highlights that simply knowing how many referrals you have made will not tell you if they have actually received any meaningful support.
Using Analytics To Identify Trends & Priorities
Having individual patient data can be useful but looking at trends within your population can help you understand why they are struggling. If multiple patients in a certain geographical area are struggling with transport it may be an issue with a lack of accessible services.
Using social determinants of health analytics software can help leaders organise their social risk data, understand the outcome of referrals and identify those within populations facing ongoing barriers. This can help with decisions around staffing, community partnerships, outreach and availability of services.
Analytics should also identify differences between relevant patient groups. This could be age, language, geographical area and other relevant factors. By looking at screening rates, referrals and outstanding needs you can identify disparities that aren’t seen in overall data. This will help you make more practical decisions around where to provide support.
Improving Coordination Between Healthcare Teams
Having clear roles within your team will help improve care. Clinicians may identify a concern, care managers may coordinate the interventions and community partners may provide essential services. Without clear processes important updates may be missed and spread across phone calls, spreadsheets and different systems.
Using Medicare patient engagement software can help you create a structured process for outreach. It can help you keep track of any attempts to contact patients, understand their preferences and identify those requiring extra support. The software should be used to support clinicians rather than replace conversations with patients.
Within your organisation you should have standard referral statuses, expectations around follow ups, escalation processes and who is responsible for any outstanding referrals. Having authorised teams with up to date information can help reduce any unnecessary duplication and improve how you respond if they need a different service or extra support.
Using Metrics To Measure Outcomes
Knowing how many screenings, calls and referrals you have made can help you understand how much you are doing but this doesn’t tell you if the patients’ situation has improved. To really understand how well you are doing you should look at the whole journey from identifying a need through to an intervention, linking them to a service and seeing the outcome.
Using care gap closure software for ACOs can help you understand any outstanding care needs and keep track of follow ups. You should look at relevant metrics to understand how well you are doing. This could include how many preventative services have been completed, how many appointments they have attended, how many referrals have been successful, how many avoidable utilisations there are and how they rate the quality of life (patient reported).
Be careful when interpreting the results as there are many factors that can affect clinical outcomes. Leaders can look at trends over time, differences between populations and why certain interventions are working or not. Having standard metrics will help you improve your processes.
Creating A Patient Focused Data Driven Care Strategy
Healthcare organisations need practical ways to understand how patients are feeling. Using social determinants of health analytics software within a considered workflow can help you understand any barriers they may be facing that are affecting their access and continuity.
Patient reported data will give you context and by keeping track of referrals and outcomes you can understand if your interventions are making a difference. Using Medicare patient engagement software and care gap closure software for ACOs can help with different aspects of your strategy.
Ensure you are prioritising identifying any unmet needs, coordinating the right support, confirming they have been followed up and learning from the measurable outcomes. By focusing on the patients’ situation you can create more responsive care pathways and work to improve care.
