By Miguel McInnis

Traditional approaches to managing high-risk populations contributed to rising costs that soared from 9 percent of GDP in 1980, to more than 18 percent of GDP and rising. Significant gaps in the care of high-risk populations, an escalating rate of chronic disease and the aging of America, add up to less than desirable outcomes.

The practice of increasing costs for increased illness is clearly unsustainable.

Since the passage of the Patient Protection and Affordability Care Act (ACA), accountability and value have become the industry’s watchwords, leading a major paradigm shift in healthcare delivery and reimbursement. In this new age of accountability, effective and cost-effective health care will require improved EHR utilization, better-coordinated care, and greater community involvement.

The Federal Health IT Strategic Plan for 2015—2020 points to the need for greater adoption of EHRs and better efforts to collect, share, and use health information toward a vision of access to health information when and where it is needed to improve and protect people’s health and well-being.

To achieve this vision, data collection and analyses must become more comprehensive. Providers need to collect more patient-centered information and Health IT needs to integrate clinical and economic data into interoperable systems that facilitate sharing, analyses, and measurement.

Significant value in the delivery of care can be achieved through the identification and segmentation of high-risk populations. Shared information across the spectrum of services focused on improving health. The development of priorities, treatment approaches, and outcomes measures are needed to guide and support clinical and economical decisions.

Healthcare management needs to evolve from isolated services departments to a model that integrates more comprehensive, patient-centered information and care. Working with common interventional strategies, clinical guidelines and decision-support systems, expanded teams led by a patient care coordinator can better serve high-risk populations. Such comprehensive approaches have demonstrated the ability to reduce ED visits and hospital readmissions, to improve health outcomes and to reduce costs.

In addition to integrating clinical care and financial data, providers need to address the external factors that impact health outcomes as well. Here are three areas for consideration:

Reducing social barriers to primary care access: the overuse of emergency services, high hospital readmissions, morbidity and premature death—exist because of socioeconomic issues. Greater community involvement is needed to improve population health. This can be demonstrated by reaching underserved populations, and by overcoming cultural, language, economic and other social barriers to primary care.

In community care: greater in-community access to care can be accomplished by engaging other community healthcare providers ( such as clinical pharmacists, visiting nurses, parish nurses, outreach workers etc.) in a networked outreach team that can see patients on a walk-in basis, deliver home care services, follow up with patients discharged from the hospital, assess risk and share vital health information critical to coordinated healthcare delivery efforts.

Leveraging community stakeholders: local community organizations such as schools, churches and charitable organizations can help educate, instruct, and support high-risk patients, which leads to a more informed population whose members take more responsibility for their own health and well being.

As the goals, objectives, and timelines of healthcare reform become clear, it is equally clear that healthcare executives need to objectively analyze internal systems and processes such as information technology and care delivery to determine how they will effectively adapt to necessary change.

New organizational strategies along with looking outward to the power of a supportive community network can lead the required adaptations and provide the means to more effectively manage high-risk populations.

Miguel McInnis is the founder of McInnis & Associates, a healthcare management consulting firm.

This article was originally published on athenahealth’s Health Leadership Forum.