As healthcare shifts from fee-for-service to value-based care and population health efforts build up steam in the industry, healthcare organizations require some solid approaches to chronic care management.

One healthcare organization, Compass Medical, has taken a variety of steps to enhance the care it provides to chronically ill patients to improve the health of specific populations of people.

“When it comes to engaging chronic patients for Compass Medical, we have many multidisciplinary teams to focus on systems optimization and process improvements, as well as a governance structure that is well suited for these projects,” said Andrew Koslow, vice president of operations and general counsel at Compass Medical. “We follow proven population health management and care management principles such as ‘Identify and Target,’ ‘Stratify and Prioritize Care Gaps,’ ‘Engage and Individualize Care Plan Activities.’”

[Register Now: Upcoming HIMSS Pop Health Forum]

In many cases, clinical management goals for patients with chronic illnesses are well-established. For example, patients with diabetes should have hemoglobin A1c tests twice a year aiming for control below 9.0 percent, blood pressure should be monitored and treated to achieve control below 140/90, and annual eye and kidney exams should be conducted to detect early organ damage, explained Dhrumil Shah, MD, chief medical information officer and a family physician at Compass Medical.

“We develop and deploy clinical management reports embedded as part of both administrative and clinical workflows for our patients with particular chronic illnesses like diabetes, monitoring compliance with these established goals, and intervening when needed,” Shah said.

[Also: To leverage social determinants of health, start with patient matching tools]

In the summer of 2016, Compass Medical launched its Chronic Care Management program across many of its practice locations, through which the organization has engaged Medicare patients with two or more chronic conditions. With the help of its EHR and Big Data platform, Compass Medical positioned itself to automate many of the workflows for care management nurses.

“This improvement enhances the non-face-to-face interactions with these patients, which is the heart of the CCM program,” Koslow said. “We also give thorough attention to Chronic Care Management patients’ individualized care plans, which incorporate personal goals and clinical goals over the long-term population health spectrum. Our efforts are continuing to give us a unique advantage to now leverage this care delivery model for Transitional Care Management and create team-based care delivery activities where these nurses are able to bridge the gaps in communication, clinical gaps and more.”

So what are next steps provider organizations should be strategically taking to engage chronic patients? Experts have varying ideas about the future.

[Also: Pop Health Forum names keynote speakers]

“First, provider organizations and payers need to share data,” said Candace Saldarini, MD, medical director at health IT firm ODH. “Shared visibility into all data that drives care decisions facilitates the development of analytics and insights to ensure chronic patients receive proper care.”

Next, provider groups must begin to integrate systems and develop tools to manage chronic patients, she added. This will help them anticipate those patients who may need more resources, measure and improve outcomes, identify inefficient providers and address deficiencies, she said.

“Rigor must be applied to assess patients’ physical, behavioral and social determinants to identify those at risk, track interventions to address the risk, and measure outcomes to continuously address the effectiveness of services and efficiency of providers,” she said.

Compass Medical will be developing more sophisticated relational databases with the goal being to achieve a better understanding of patient compliance with recommended clinical management goals and to improve patient experience through practice redesign activities.

“We are actively working on care management and population health management platform agile development and deployment in order to create a scalable model that utilizes data science and clinical science in synergy to improve ongoing engagement and drive positive outcomes,” Shah said. “We are also working on maximizing our patient portal and mobile patient engagement platform functionalities while integrating valuable data insights with ongoing care management and clinical workflows.” 

Koslow and Shah will be speaking on Compass Medical’s population health efforts during a session entitled “Data driven insights in chronic care management innovation” at the HIMSS Pop Health Forum that takes place on October 2-3, 2017 in Chicago. 

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com