Value-based care is a team effort

June 11, 2021 / By Steve Delaronde

The three-legged stool that supports primary care in a successful value-based practice includes data analytics, care coordination and patient outreach. The primary care provider (PCP) cannot perform all these roles, however. He or she needs to own the clinical care of the patient and leave the rest to the data analyst, care coordinator and outreach worker.

Data analytics

The average primary care panel size is between 1,200-1,900 patients per PCP. Multi-clinician practices have even more patients attributed to their collective care. Access to longitudinal clinical and social risk data is imperative to know which patients require chronic condition management, preventive care and wellness visits, as well as identifying those at risk of an emergency department (ED) visit, hospitalization or other adverse event. Data sources need to be broad and regularly updated to refresh classification and predictive models, as well as provide quality outcomes tracking. A comprehensive patient classification tool is the foundation of effective care coordination.

Care coordination

Care coordination is not case management. Case management tends to focus solely on a patient’s medical needs and often targets specific risk groups, such as patients with complex or chronic conditions. Care coordination considers the needs of the entire patient panel and employs a broader model that addresses the biological, environmental and social determinants of health. The care coordinator facilitates the transformation of analytics into action.

Patient outreach

Outreach workers are often- overlooked resources that serve as a critical component of a patient’s overall wellbeing. Home visits provide information about a patient’s living environment, which can be useful in developing a treatment plan. Bare cupboards, unsafe neighborhoods and challenging living conditions can be more easily identified and addressed when a patient is observed in their own environment.

Virtual video visits are also an option for patients with broadband access and the technology needed to make this connection. Virtual care is particularly important for elderly and rural patients, even if it is just telephonic. Like many other outreach organizations, Papa, an on-demand assistance service, had primarily offered companionship and assistance to older adults through home visits, but now offers virtual companionship due to the demand that resulted from the COVID-19 pandemic.

Next steps

The integration of analysts, care coordinators and outreach workers into primary care ultimately allows PCPs to perform the role for which they were trained, while improving the opportunity to achieve the results that are expected from a value-based model. Ambient intelligence that allows the provider to focus on the patient and not the computer screen is an important contribution to enhancing the patient-provider relationship. Finally, an accessible and affordable care network to which the provider can refer, and the patient will utilize, ensures that the contributions of the analyst, care coordinator and outreach worker will achieve the intended positive outcomes.

Steve Delaronde is senior manager of product, population and payment solutions at 3M Health Information Systems.

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