Easy to become disconnected
Of patients 50 years or older, 76% leave the hospital or physician’s office confused about what to do next, while 50% of adults have trouble using or understanding health information.
To shoulder greater accountability for outcomes, health systems must partner with patients to close gaps in communication and coordination while managing care beyond the acute care or physician office setting.
This study offers nine imperatives to improve patient engagement across three areas.
Recover lost value in episodes of care
Health systems must first engage patients in traditional episodes of care. Limited patient engagement can lead to variable cost and quality outcomes, which hinder a system’s ability to capture full reimbursement and compete against other providers for new patients.
When patients access the care delivery system for a specific health care need, organizations must set clear expectations for patient responsibilities, support patient self-management in recovery, and establish feedback loops between patients and providers to identify complications early.
Create new value through ongoing care management
For organizations assuming population health risk, driving down the long-term cost of care for attributable individuals requires better day-to-day management of chronic conditions and earlier use of lower-acuity sites of care. However, given limited resources, most health systems will not be able to aggressively manage care for everyone.
Organizations must therefore deploy their care management infrastructure in a targeted way. To create new value through ongoing care management, organizations should:
- Identify and prioritize support to the highest-risk patients
- Leverage data to identify changes in the health status of well-managed patients
- Open easy access points to promote low-acuity utilization
- Support ongoing self-management of the entire patient population
Add value through population management
Organizations assuming ongoing care management have the opportunity to extend the care management enterprise to engage whole communities. In partnership with other community stakeholders, organizations must prioritize health system population management activities against the greatest community needs and align with community groups to spur population health.
By reading this study, members will:
- Understand how the care management infrastructure can engage targeted groups of patients in ongoing chronic care management and preventive care
- Evaluate opportunities to improve patient engagement during specific episodes of care across treatment and recovery
- Explore the role of the health system in longterm population health through partnerships with other community health stakeholders
Patient Self Management
Chronic Care Management
Care Team Building
Access to Care