In an increasingly challenging and ever-evolving healthcare market, specialty provider organizations confront many challenges that demand innovative technology solutions. One urgent concern is the transformation of chronic care management to help ensure the best patient outcomes while efficiently handling the most complex cases.
According to the World Health Organization (WHO), 87% of deaths in high-income countries result from chronic conditions. A survey conducted in 2018 indicates over half (51.8%) of US adults have been diagnosed with at least one chronic condition, such as arthritis, cancer, chronic obstructive pulmonary disease, coronary heart disease, current asthma, diabetes, hepatitis, hypertension, stroke, and weak or failing kidneys. And 27.2% have comorbidities.
Chronic conditions make it hard for specialty providers to provide thorough care without continuously tracking the full care journey and taking action at the right moment. For example, When developing care plans for cancer patients, considering any other chronic conditions can lead to better outcomes.
Given the lengthy care episodes typical among specialty practices, monitoring multiple conditions to improve care planning and care delivery becomes a formidable task. This issue intensifies as practices grapple with insufficient staffing, rising patient volumes, and escalating care costs.
Specialty practices address complex conditions, such as cancer and chronic kidney diseases. Identifying these conditions at an early stage eases the process of reversing or managing their progression. This highlights the crucial importance of Advance Care Planning (ACP), which CMS endorses for comprehensive care management within specialty practices.
Primary care physicians bear the responsibility of initially identifying conditions and, if necessary, referring patients to specialists. Following this, medical assistants in specialty practices oversee the management of these referrals.
For specialty provider organizations, advanced care planning serves as the foundation for personalized, patient-centered care management. By comprehending each patient's goals and preferences, care teams can tailor treatment plans to best align with the patient's needs and wishes, ultimately enhancing the quality of care provided.
Additionally, specialty practices must improve their triage protocols, ensuring that patients needing in-person care receive priority. But to achieve this, care teams need modern technology that provides longitudinal patient records, which give them the most complete patient profile, enabling enhanced care management through evidence-based care protocols.
Specialty provider organizations often work with patients grappling with advanced chronic conditions, often compounded by comorbidities. Given the potential for multiple conditions to increase complications and healthcare utilization, managing comorbidities becomes a vital aspect of chronic care management.
Ineffective chronic care management can't occur without interdisciplinary coordination, extending beyond individual care episodes. Two essential elements for effective collaboration between primary care providers and specialty practitioners are advanced care planning and thorough patient data.
Longitudinal patient data serves as a key for specialty providers. With a complete, 360-degree view of patient data, practitioners can better personalize care plans for their patients. For example, chronic kidney disease (CKD) often accompanies other conditions such as diabetes, hypertension, and heart disease. CKD patients are naturally more prone to develop these comorbidities, which can accelerate kidney disease progression and increase the complexity of healthcare management.
Having a comprehensive view of patient data allows specialty providers to create comprehensive care plans that address the patient's comprehensive health profile. Let's call these holistic or patient-centered care plans. This process involves ongoing monitoring, managing medication, lifestyle changes, timely interventions, and patient education. By concentrating on effective comorbidity management, specialty provider organizations can significantly improve patient outcomes compared to plans that focus on the specialty condition alone.
Amid expanding care gaps and the lack of automated worklists, care managers grapple with the burden of time-consuming and error-prone manual administrative tasks of gathering reminders, confirmation texts, searching for patient information, and dispatching messages to patients and fellow team members.
Without substantial access to data-driven reports and insights that measure the influence of care management activities, care teams find it difficult if not impossible to track the effectiveness of their care programs. Moreover, communication obstacles between providers and patients lead to poor adherence to clinical appointments, medication plans, lifestyle changes, annual wellness visits, and so on.
The solution to these problems resides in data-driven, automated care protocols that establish the foundation for comprehensive care coordination and management. By implementing proven automated care protocols, specialty providers can ensure that patients receive the most appropriate, timely care and support during their transition period from hospital settings to rehabilitation centers or nursing homes. This includes medication reconciliation, patient education, and post-care follow-ups. This active approach can help stave off complications, decrease hospital readmissions, and enhance patient outcomes.
Transform End-To-End Care Management for Your Specialty Practice
Enabling end-to-end healthcare data integration is the first step to enable smooth care delivery, as data is required for all manner of analytics, including risk stratification, network performance, and addressing coding gaps. Specialty care organizations need to collect patient data from multiple sources and harmonize them into a standardized format. Gaining access to accurate, complete, and timely data from all relevant sources across care settings—EHRs, labs, pharma, SDoH, and so on—is a common missing link, and the starting point to enable care teams to access rich, actionable insights and integrated workflows that help them effectively manage multiple protocols.
Innovaccer's specialty care management solution—which uses the Innovaccer platform’s unified patient records—provides automated alerts, empowering providers to focus on patient recovery instead of struggling with administrivia, such as follow-up reminders and appointment scheduling. Furthermore, these proven protocols are adaptable and customizable according to the provider’s specific requirements. For example, specialty providers can have unique protocols for hospital discharge and ED discharge.
With care management powered by Innovaccer’s industry-leading healthcare data and analytics platform, specialty providers can easily identify high-risk patients through predictive analytics right at the point of discharge. They can also reduce readmissions by analyzing ADT feeds, claims profiles, and SDoH data to consider targeted interventions.
Care management protocols (IP and transitional) can play a vital role in reducing hospital readmissions, improving patient outcomes, and lowering healthcare costs. By adhering to these protocols, specialty providers can ensure that patients receive the right care at the right time throughout their transition period, delivering higher quality care that produces better outcomes and higher patient satisfaction.
For a complete understanding of how Innovaccer's industry-leading healthcare data platform and specialty care management solution can help you take care management to a higher level, schedule a demo with our healthcare experts.