chronic disease and population health management

Smart Technologies inChronic Disease &

Population Health ManagementThe case for outcome-based

approaches to better healthcare

© 2016 Napier Healthcare. All Rights Reserved.

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Smart Health Technology IntegrationBetter Chronic Disease Management and Patient Experience


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Our research shows the following to be true:- Chronic Disease Management (CDM) requires holistic case management.

Remote monitoring of vital signs is achievable today.

Longer term care plans for chronic diseases will vastly improve quality of care.

With sufficient data, analytics will further drive successful health outcomes.

Mostly with elderly and increasingly with younger patients, we have to personalise the experience when they visit the facility. For instance, we should

Consider an easier Registration process or NO PROCESS at all

Use voice based GPS and WhatsApp

Chronic Disease Management and Patient ExperienceWhat is to be Done?

The 2015 report by DesignSingapore Council, Design for Ageing Gracefully–Rethinking Health & Wellness for the Elderly: Public Services, tells us that seniors:

Are very comfortable using WhatsApp, Viber and Skype, for long distance calls and to exchange photos etc. Those in the higher-income bracket (HDB 3 and above) tend to use tablets and smartphones.

Can we use WhatsApp to design a user experience for when they visit the hospital? Of course, use bigger fonts in the messaging interface, always.

Don’t like tech-enabled check-ins or SMS-based check-ins—it is too impersonal.

Prefer familiar faces in the Care team. They don’t want to meet new people at every visit.

Want “recreation” facilities in hospitals, if possible. Going to a hospital makes them feel “unsafe” and usually denotes trouble.

What can we do to make them safe? Why not have Wellness integrated instead of only sick care? Feel under represented in healthcare delivery.

Can we hire the elderly to take care of the elderly?

Watch a lot of TV.

Can that be used as a medium of interaction?

So what can we do?

Patient ExperienceA Call for Empathetic Technology


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Enhancing Patient ExperienceEmpathetic Tech-based Options Available


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Technologies provide for the THREE keys to better patient experience:Communication, Access to Information, Doctor/ Patient Relationship

Radio Frequency Identification (RFID) tagso Combined with location aware beaconso Tracks the location of patients moving through the systemo Alerts hospital staff of patients’ arrival/presenceo Automatically sets environmental controls based on patient preferences

Wearable technology to increase physicians’ face time with patientso Sends AV feeds from patient consultationo Scribe accesses the EHR remotely and enters patient noteso Patient notes are reviewed and signed off by the doctor

Mobile apps, kiosks, portals etc.

Analytics to find at-risk populationo Helps people manage their health conditions at home—long before they reach an acute stageo Reduces readmission rateso Uses: remote monitoring devices connected via Bluetooth, a Cloud, digital chart displays

Population HealthA Holistic Approach to Chronic Disease Management


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Population HealthThe Health Outcomes of People in a Community


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Population Health Management (PHM)

What is it?

Goals Why is it needed?

Benefits

Set of interventions designed to maintain/improve health of population across the full continuum of care.

Covers low-risk healthy individuals to high-risk individuals with one or more chronic conditions.

Population: Better coordinated care

Physicians: Better informed and engaged with patients

Health Care Organizations: Improved clinical outcomes and reduced costs

Health Care System: Increased preventive care and closed care gaps

Address burden of undiagnosed chronic illness that later present as acute condition

Address higher costs on the system due to chronic illness

Improve health of patient population

Redefine healthcare as a set of interdependent activities

Mitigate risk factors that exacerbate illnessSource: International Diabetes Foundation

(www.idf.org/membership/wp/ Singapore)

Singapore Health TodayAgeing Population and Rising Incidence of Chronic Diseases

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Disease Prevalence (18-69 years) - 2010

Hypertension 23.5%

Diabetes 11.3%

High Total Cholesterol 17.4%

Obesity 10.8%

Daily Smoking 14.3%

Sources: Department of Statistics; Ministry of Health, Singapore; AIA Vitality Age Survey 2012, Ministry of Health Disease Burden

By 2030, the number of elderly citizens (aged 65 and above) will be 900,000.

Leading causes of death: major non-communicable diseases such as cancer, coronary heart diseases, strokes, pneumonia, diabetes and hypertension.

Common risk factors: smoking, obesity, physical inactivity and alcohol consumption.

Moving Forward with Accountable CareThe Future of Healthcare Delivery is Outcome-Focused


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The Accountable Care ModelBased on Accountable Care*, Focused on Outcomes

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Accountable Care/ Affiliated Care Network

Affiliated Care Network between general physicians and hospitals (enabled by a referral system between GP’s and hospitals)

Remote patient monitoring solutions aid in preventive approach to care (both for chronic diseases and ageing population)

The focus is on management of chronic diseases for people in a community.

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* Accountable Care ties provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients, and is an increasingly important, Federally sponsored initiative in the USA.

Napier Healthcare is Ready to DeliverHigh-Value and Cost-Effective PHM on the National Scale


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The Napier Advantage Enhancing healthcare delivery with an outcome-based model

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Chronic Disease Management – Population Health Management

National Electronic Health Record (NEHR)

Care Coordination

Care Plan&

Vital Signs Monitoring

Portal

Analytics

Case Management

such as Pega or CRM currently in

use

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To take this concept to fruition, we must work with government agencies:IDA, MOH and the Smart Nation Program Office.

Existing / Maybe

New Solutions

Transitions of Care

& Referral Management


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APPENDIX

Framework: Population Health Management (PHM)The Continuum of Care and Patient-Centered Interventions


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Source: CareContinuum Alliance, A Population Health Guide for Primary Care Models, 2012

The PHM WorkflowSteps in the Provision Model


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Stratify, Design & Monitor Population

Identify Gaps in Care

Stratify Risks

Engage Patients

Managed Care

Measure Outcomes

PHM Workflow Chronic Disease Management

Identify the disease profile (e.g., Diabetes) along with the target population based on demographics and risk factors

Health assessment: Map the risk factors and the gaps in care at all levels—preventive, primary and above

Identify and stratify the population based on the level of risk involved (gaps in care, demographic, social etc.)

Community outreach and patient engagement programs

Technology enabled chronic disease management program to reduce the gaps—referral program, health promotion, risk management etc.

Remote patient monitoring to measure the outcomes of the program

PHM: Key ComponentsFoundation for Comprehensive Care and Management of Costs


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1. PhysiciansProvide care consistent with PHM goals

2. Primary Care Physicians/General PractitionersThis group enables scalability for larger populations

3. Data AnalysisData is aggregated from EMRs, ePrescriptions, Practice Managers, Payers, HIEs and Labs to be analyzed for actionable outcomes

4. Benefit Program CoordinationFinancial incentives to be offered for participation in PHM

5. TechnologyEnables information to be pushed to patients

6. Referral MechanismEases the path along the continuum of care between primary and tertiary levels

7. Physician IncentivesEnsures involvement at PCP level

8. Replication AbilityApplied to community at large

Analytics in PHMLaying the Path to Actionable Insights


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Source of Data Action Items

Electronic Medical Records

Electronic Prescriptions

Practice Manager Data

Payers Information

Hospital Information Exchanges

Laboratories

Data Analysis

Deliver Preventive Care

Treat Chronic Diseases

Perform Patient Outreach

Assess risk and Analyze cost

Report Outcomes and close care gaps

Clinical data (Biometric, Lab & HRA data)

Utilization data (How do people access/ use healthcare?)

Adherence data (Care plans, Medication plans & Preventive care)

Operational data (Participation, productivity, disability data and other metrics)

Financial data (How does healthcare activity translate into dollars (savings)?)

Satisfaction data (How participants/ stakeholders view your efforts?)

Top Areas for Data Analysis

Source: Health Intelligence Network, Napier Analysis

Technology Adoption in HealthcareThe Factors Influencing IT Investments


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Source: Technology in the NHS—Transforming the Patient’s Experience of Care

THANK YOU

w w w . n a p i e r h e a l t h c a r e . c o mi n f o @ n a p i e r h e a l t h c a r e . c o m

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