Posted by: Jenny Laurello
coordinated care, health IT tools, longitudinal care, proactive care, Risk assessment
The need for coordinated, proactive care focused on caring for chronically ill, high-risk, multiple comorbid patient populations is becoming a critical focus for health care providers as accountable care organizations (ACOs) begin to gain traction.
Providing advanced solutions utilizing cloud-based eHealth application development, Mayo Clinic and the Noaber Foundation co-founded VitalHealth Software in 2006 to address just this very need. This unique platform focuses on point-of-care patient population management to help bend the cost and quality curve and improve outcomes. Conditions targeted include diabetes, chronic obstructive pulmonary disease, asthma, Alzheimer’s, multiple sclerosis, eczema, schizophrenia, obesity, and smoking cessation. The functional design was conceived to be effective utilizing role-based, multi-disciplinary views, coordinated scheduling, structured intake forms, risk assessment, decision support with alerts based on scientific guidelines, referral management, outcome reporting, and patient self-management. On the technical side, the architecture had to be cloud-based, web-enabled, and integrated with existing EMRs and labs.
As a leader in health care delivery, Mayo Clinic leveraged this platform to assist with its goals of better managing primary care patients. Mayo wanted a system “to enable longitudinal care compared to ‘usual’ episodic care, … providing preventive services for 140,000 patients (cancer screenings, immunizations, metabolic screenings and wellness counseling), chronic disease management for patients with hypertension, depression, diabetes, asthma, CAD (coronary artery disease), and CHF (congestive heart failure).” The goal was to engage “allied health staff to offload responsibilities from MDs both at population level and for patients being physically seen for preventive care and care for chronic conditions so that our MDs can spend their valuable time caring for patients and not … searching for information.” Data revealed that time saved per patient for preventive services, diabetes and CAD care was 3.9 minutes per patient for MDs, 2.7 minutes per patient for licensed practical nurses, and 2.17 minutes per patient for administrative staff. A number of clinical studies resulting from this implementation have been published, validating reduced hospital readmissions in frail elderly, increased advance care planning, and higher rates of osteoporosis screening.
For organizations going down the path of stratifying and managing patient populations, tools become a critical component of the health IT environment and a key enabler for assuming the risk-sharing required under accountable care models, patient-centered medical homes, and clinically integrated networks — while enhancing quality and outcomes of care.