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Population Health knowledge hub

Learn how successful population health management can benefit your patients and your medical organization.

Population health management tools to identify and engage patients in need of care

Without the proper population health management tools, it’s difficult to identify the patients in your population who need attention, engage them, and coordinate their care.

Good population health management tools provide visibility into your patient base to see, for example, who needs routine care, such as physicals, diabetes management, mammograms, colonoscopies and other screenings. This enables organizations with volume-based reimbursement to responsibly increase volume – and therefore revenue – while better serving their patients.

Organizations with value-based compensation can use population health management tools to identify patients who have been treated but not yet attributed to a risk contract, as well as those who were treated out of network, so they can be offered in-network alternatives that can be more closely monitored. Both of these strategies are important to better care and profitability in a value-based model.

In addition, quality rewards are often based on providing particular tests or treatments to certain populations. Population health management tools should enable organizations to easily identify such populations and provide notifications during the clinical process that those tests or treatments are due. Organizations can also create campaigns of increasing intensity to get patients to come in for the tests and treatments they need, using reminder e-mails or text messages, and following those up with phone calls. Again, this approach can increase both quality of care and revenue.

Population health management tools must enable you to do more than identify various kinds of patients. Until you engage the patients you’ve identified, they are just statistics on your spreadsheets. And in the age of electronic consumerism – even in health care – engaging them means being able to communicate with them through emails, text messages, phone calls and voice messages. True patient engagement also requires:

  • Enabling two-way communication with patients to keep them on track while efficiently answering questions about their care; this is often best achieved with a patient portal that enables the secure exchange of messages between patients and a health care organization.
  • Communicating results of third-party orders (such as labs) to patients in order to guide their behavior; again, a patient portal can be an enormous help in maintaining this connection and effectively making results available.

Without this kind of engagement with patients, population health management efforts are doomed from the start.

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