How Connected Care Improves Outcomes In At-Risk Populations

Digital health technologies are driving new opportunities for connected care. Value-based payment models serve as the financial foundation through which providers can explore how to implement them.

Research from the Commonwealth Fund found up to one-third of U.S. adults do not see a doctor when sick. They also do not fill their prescriptions, a behavior often noted in at-risk populations, including older adults and individuals with chronic diseases. Digital health tools are connecting patients to care and supporting adherence to evidence-based best practices.

What’s driving connected care? 

The pandemic has spurred exponential growth in virtual care services, demonstrating what we can accomplish outside of traditional care settings. Patients are demanding services that better meet their schedules and preferences. With remote patient monitoring, hospital-at-home initiatives, telehealth, and rapidly evolving digital health tools, there are more opportunities for connecting with patients than ever before.

How technology, innovative care delivery, and payment models can help

To achieve comprehensive, connected care, providers must use new technology and integrate it into their workflow. Providers are exploring new platforms, apps, and vendors to connect patients to necessary services where and when it’s convenient for them. 

But these technologies come at a cost. Implementing tools that improve outcomes can be expensive and often there is no payer reimbursement to offset these expenditures. This is not a sustainable business strategy. Value-based payment models that provide reimbursement outside of the fee-for-service framework can make these investments worthwhile.

Tools and processes boost patient experience

A patient whose low back pain improves after treatment may still be unhappy with their experience if they can’t access their provider between appointments. At-risk patients want to receive care with the same ease and convenience that’s now commonplace in other consumer experiences.

Patients want to feel fully supported by their providers without making multiple phone calls, dealing with repetitive paperwork, or waiting for answers to questions. Providers who address these wants and needs reap the rewards with favorable patient experience scores.

Connected care and engagement can be supported by:

• Text reminders for upcoming appointments, including prep instructions and other essential information, like applicable COVID-19 protocols.
• Mobile health history intake apps that enable patients to avoid paperwork by providing information through their phone or a kiosk.
• Online bill pay, appointment scheduling, post-appointment patient experience surveys.
• Virtual waiting rooms, technologies that enable patients to check in for outpatient appointments from their car and then go straight to an exam room when ready.

As consumers grow increasingly familiar and confident with these tools, their health—and the patient experience—improve. The result is engaged patients who have a more consistent care regimen and can manage more of their care on their own. 

Effective communication improves patient engagement

People in at-risk populations are particularly vulnerable to breaks in care continuity, which is why effective communication is essential. At-risk populations are more likely to face social risk factors, such as a lack of transportation to specialist appointments or food insecurity.

New tools to identify, address, and manage social determinants of health are available. And collecting data on social risk factors is becoming commonplace. But providers are often hesitant to screen for these issues if they do not have access to resources to help patients address them. 

Payers and providers with aligned incentives and flexible value-based payment models can implement these tools to provide the right type of communication at the right time and improve patient engagement and outcomes.

Support at-risk populations with preventive care

People in at-risk populations—older adults, those with mental health conditions, or those managing chronic conditions—often end up receiving emergency care. This type of last-minute care is the least ideal option. It’s the costliest way to treat patients, and patients who end up in the emergency department can have difficulty recovering and receiving continuity of care.

These at-risk populations can benefit from services to prevent chronic disease or prevent it from worsening. Preventive care can keep them healthy, treating conditions before the situation becomes dire. But many at-risk patients don’t have access to these services. Comprehensive, connected care involves analyzing and stratifying patient data to determine who is at risk and then coordinating outreach so that patients receive timely tests and screenings. 

At-risk populations can be supported with preventive care, including:

• Help patients access preventive therapies, such as pharmacy discount programs.
• Offer telehealth when appropriate, which a growing number of providers are using for mental health services.
• Facilitate scheduling of follow-up appointments before patients leave the exam room so that the onus for continuity isn’t on the patient.
• Recommend at-home services when appropriate.

Final thoughts on comprehensive, connected care

Improving quality and outcomes in at-risk populations requires more of providers when resources are already strained. Using technology and innovative care delivery models can lessen the burden while helping both patients and providers realize significant benefits. Value-based payment models serve as the financial foundation through which providers can explore how to implement new technology and best practices. These efforts will also curb unnecessary spending, bringing us closer to embodying the tenets of value-based care.