Population insights and care management

Care transformation through a patient journey

How a collaborative care ecosystem impacts every stakeholder


Imagine the impact on healthcare of an open ecosystem of integrated solutions and technology that can help anticipate and meet a wide spectrum of health needs. Such a solution would need to offer open architecture, allowing patients, providers, payers and caregivers to easily and seamlessly connect.
 

The power of this ‘open ecosystem’ solution to deliver more collaborative care across the continuum is perhaps easiest to understand when viewed through its impact on a fictional family – albeit one that shares issues with many real-life families.

A familiar experience for some seniors

 

Albert is 76 and has lived alone for the past two years, taking multiple daily medications, including one for hypertension. Unfortunately, his failing memory causes him to forget to take his medications more and more frequently, which is giving him dizzy spells. Recently one of his dizzy spells resulted in a fall. Later that day, his daughter happened to stop by and he was admitted to the hospital.

The difference a connected ecosystem can make

 

During Albert’s hospital visit, all of his health information was aggregated into the Philips population health management platform – a robust digital ecosystem that the hospital’s care managers use to stay well informed about the health and risk of their patient populations.

Armed with this knowledge, they were able to easily develop longitudinal care plans and put a care plan in place, so that their knowledge could be readily shared with providers and care locations after his hospital stay.

Extending care in the home for independent living

 

Albert is enrolled in new remote patient monitoring and medication management programs, equipping him with a tablet and connected devices he could use at home to dispense his medication, capture his vital signs, respond to surveys, and video chat with his care team. The team could receive alerts when his blood pressure was out of range based on their protocols. His case manager also recommended that he receive an emergency response pendant.

Benefits for providers

 

In addition to being able to manage Albert remotely, care protocols allow his provider to identify changes in symptoms, prioritize outreach and intervene earlier before health events escalate. The practice now also receives alerts for all ACO patients that surface directly into the EHR, so they can proactively anticipate and mitigate gaps in care. This has enabled the practice to qualify for bonus payments tied to achieving the Triple Aim and allowed it to consider taking on additional risk contracts next year.

Benefits for health systems

 

The ACO is also reaping the rewards of these connected digital solutions. Using them to help manage risk and care for its Medicare enrollees has been an important factor in its ability to measurably reduce its emergency department visits and avoidable admissions this year. The ACO can now easily identify and stratify patients by risk, then give its care managers the data and insights they need to proactively navigate patients to appropriate preventive care.

Proactively detecting risk

 

Things have gone well for Albert in the past few months, but the emergency response service identified a changing pattern of use of the service. The predictive analytics solution from Philips helped identify that Albert was at increased risk for emergency transport in the next 30 days. Concerned about this trend, the care manager reviewing the predictive analytics system notified his family and scheduled a home nursing visit, after which he was prescribed new medication.

Visions of a happier ending

 

Supported by his family and connected to his care team, Albert no longer fears having to leave the comfort of his home to go to an assisted living facility and his family enjoys greater peace of mind.

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See how a program demonstration featuring home-based monitoring, connected devices, care management and telehealth could impact the outcome of one hypothetical patient after a fall and hospital stay.
Philips Population health management: A model for collaborative health management outside of the hospital
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