The last of our country’s baby boomers are reaching retirement age, making them eligible for Medicare. When this younger group of ‘trailing edge’ boomers joins the ‘leading age’ boomers (seniors approaching 80 years), Medicare enrollment will catapult to 80 million beneficiaries by 2040.
Our senior population is living longer and presents more complex healthcare needs than previous generations. The National Council on Aging reports that 80% of older adults have one chronic illness while nearly 70% have two or more – meaning more people than ever before will rely on our nation’s healthcare delivery system.
In turn, establishing an effective population health management strategy is even more critical for health plans trying to control increasing costs and promote healthy living among older adults, particularly those with chronic disease.
A Data-Driven, Analytic Approach is Key to Effective Population Health Management
Health plans rely upon timely member health information and data-driven insights to proactively manage care. Given that post-acute care (PAC) settings treat older, higher acuity adults, many of whom have comorbid conditions, they represent a prime opportunity to improve care outcomes and reduce costs. Therefore, post-acute analytics plays an integral role in capturing real-time member data, delivering appropriate treatment, and informing care coordination efforts.
Real Time’s Interventional Analytics connects payers with their PAC providers, giving them access to key clinical data from disparate post-acute electronic health records (EHRs). By analyzing live member data from various post-acute EHRs, Real Time provides timely, actionable insights enabling health plans to:
- Identify emerging population health trends for high-risk members
- Assess, stratify, and prioritize all members using live readmission risk scoring to close gaps in care and avoid costly rehospitalization
- Improve successful transitions of care between treatment settings or back to the community
Leverage Post-Acute Analytics to Improve Member Health and Reduce Costs
After hospitalization for injury or illness, four out of ten Medicare patients are discharged to post-acute care. Unfortunately, up to 12% of them, particularly those with chronic disease, are readmitted within 30-days. Using post-acute analytics, health plans can reduce this cycle of avoidable readmissions by prioritizing care for high-risk members and implementing clinical pathways for chronic disease management.
Real Time enables health plans to focus on their chronically ill, high-needs members in the moment. Using the Real Time Risk Scoring tool, plans can identify and monitor members at risk for rehospitalization. The tool detects subtle changes in clinical conditions and sends live notifications to PAC and health plan care teams with suggested interventions when data indicates the potential for negative outcomes. This way, payers can collaborate with PAC providers regarding the recommended treatment for high priority members. For example, a heart patient with slight weight gain, shortness of breath, and edema would trigger an alert indicating when and why that member needs prioritization and what clinical interventions are required for stabilization. Armed with this information, plans can monitor members on a daily basis with keen awareness of those at-risk or in decline.
Leveraging Real Time’s live patient data, payers can also work with PAC providers to jointly develop standards of care pathways for chronic disease management. Upon admission to a skilled nursing facility (SNF), health plans often approve care solely for the member’s primary diagnosis, not knowing or accounting for additional chronic conditions that should be addressed. SNFs are then required to submit authorization requests and wait for approval to treat the additional health issues they’ve detected, potentially impeding patient progress.
By implementing data-driven, standardized care pathways for specific diagnoses, health plans can reduce treatment variability and prioritize care for members with chronic disease. Establishing clinical pathways also ensures timely, appropriate interventions are applied for all medical conditions during the SNF stay. Treating chronic illness in the facility instead of the hospital or emergency room also ensures continuity of care while reducing unnecessary readmissions.
Assessing Activities of Daily Living and Social Determinants to Ensure Successful Discharge
Health plans can also leverage ADL scores to determine discharge readiness for healthy members without chronic conditions who are successfully progressing with low to no risk. These members typically rank higher on ADL assessments and require less recovery time than the average 10-day PAC episode of care, thereby lowering length of stay and reducing healthcare costs.
With access to live post-acute analytics, health plans can engage high-risk members in the PAC setting at the right time with the right interventions, influence member treatment during the post-acute episode of care, ensure safe and timely discharge planning, and identify trends and opportunities to improve overall population health.
About the Author
As the Vice President of Payer Solutions, Jim is responsible for the growth of Real Time’s solution offerings to health plans nationwide. Focusing on Medicare, Medicare Advantage, and Managed Medicaid Jim works with our health plan partners to improve clinical, financial, and care outcomes for members’ post-acute care journey.