Every patient – you, your mother, your grandmother, your adult children – especially those with serious diagnoses and chronic illnesses – longs to be cared for by the healthcare system in a way that demonstrates they are truly known.
Patients have some sense that this is, in fact, possible. Just think about what Amazon and Alexa know about you:
- Your music playlist and preferences,
- What you've searched for on Amazon, Zappo's and Diapers.com,
- When packages are expected to arrive at your house and more importantly, what's inside the boxes,
- What time you get up and go to bed.
And then think what Amazon can surmise about you with all of this information. Certainly your music listening behavior provides insight into how often and for how many minutes you exercise. The tone of your voice, coupled with other information such as your music choices, communicates your mood, and over time, likely some insight into your mental health. Perhaps your health status and conditions too, especially if you order cold medicine, diabetic supplies or blood pressure medications from Amazon or its subsidiary PillPack.
At the same time, too many healthcare organizations and providers don't know enough about the patients they care for and the populations they manage.
Let me tell you about Joseph.
Joseph and his wife, Sofia, live in Bedford, New Hampshire, nearly 45 minutes from their youngest child, Lucy. Joseph is in his early 70s, is retired and lives on a fixed income, and has two chronic conditions: diabetes and congestive heart failure.
In many ways, Joseph is a typical American patient.
- Chronic Disease Prevalence: 60% of adults have one chronic disease, and 40% have two or more.
- Diabetes: 30+ million adults have diabetes as do more than 25% of seniors.
- Social Determinants of Health: Nearly 70% of adults have unmet social needs, such as financial insecurity or loneliness. Like Joseph, almost a third of Americans experience stress over transportation needs. He also is challenged by a language barrier and a low, fixed income, which could adversely impact his access to healthcare and medication.
In very important ways, Joseph's experience is far from typical.
His hospital, its physicians and staff know him and engage with him in a way that makes him – and his wife and only daughter, Lucy – feel cared for and connected to his hospital and its physicians.
From his hospital's perspective, Joseph's experience is the result of its focus on:
- Readmissions and the connection to congestive heart failure. Using Geneia's Theon® Platform for Analytics and Reporting, Joseph's hospital determined that its readmission rate is nearly 11% and congestive heart failure accounts for 61% of readmissions.
- Leakage. Joseph's hospital used its analytics and reporting platform to understand which out-of-network services were being used by patients like Joseph. The hospital has long lost cardiac patients to renowned hospitals about 60 miles away, which is why it created a transition of care program and a complex care management program to better serve and retain cardiac patients.
- Quality measures. The hospital knows which areas to prioritize and improve to support HEDIS® and Star ratings as well as to generate the revenue associated with the value-based care contracts its physician practices have. That's why Joseph's physician and his staff were tracking Joseph's open care gaps and helping him to close them.
- Digital front door. Joseph's hospital has deployed a digital front door strategy – with a patient relationship management platform as the foundation – to engage patients at every touchpoint along the patient journey.
For Joseph, this means that when he interacts with his complex care management nurse or his primary care physician's office, they know his priority healthcare needs such as his open care gaps as well as his social determinants of health (SDoH).
For the hospital, the digital front door strategy means, for example, it can do educational outreach about the strengths of its cardiac program to all newly diagnosed heart failure patients such as Joseph, those at risk for heart failure and their spouses.
Proactive outreach and care coordination, facilitated by the hospital's use of Theon® Analytics & Reporting, are the heart of its success in knowing and caring for Joseph and better managing readmissions, leakage and quality measure performance.
*Joseph, Sofia and Lucy are fictional and not intended to represent any specific person. This information is provided for illustrative purposes only.