Blog Post | July 21, 2017

Hospitals Face Daunting But Not Impossible to Overcome Population Health Challenges for Patients with Advanced Illness


Problems with a Generalist Approach to Population Health Management

John Halsey Turn Key Health

John Halsey
VP, Business Development

While many hospitals have general population health management (PHM) solutions, they need to identify and implement a more effective way to optimize their programs for seriously ill patients.

Too often, a generalist population health approach lacks specificity with unrefined analytics that simply tracks the member’s disease process rather than placing a specialty focus on advanced illness and end-of-life as they relate to the individual’s goals of care.

In fact, the majority of current solutions miss the mark when it comes to forecasting what will actually happen to the patient, and fall woefully short in transitioning from disease or event-specific care management to a patient-centered approach that addresses the individual.

Palliative Illness Management ™ — A Better Approach

A better alternative is a predictive model such as PIM™ where sophisticated analytics and proprietary algorithms do not simply identify patients at risk of death in the near-term or identify potential high-cost patients. Check out Turn-Key Health Palliative Illness Management Solutions for additional information.

Instead, the model identifies patients at risk of over-medicalized care and ultimately, over-medicalized death in the next six months.

It is designed to integrate with a specialized community-based palliative care model that enables patients to remain at home, avoid non-beneficial treatment and avert hospital readmissions. The candidates identified are high opportunity rather than simply high cost.  This results in a higher return on quality improvement and investment in resources.

Optimizing PHM with Specialized Palliative Care to Avoid Re-admissions

This is where a unique model like PIM™ is so valuable.  It uses an optimized predictive model to not only identify high-opportunity patients but is also designed to integrate with a specialized community-based palliative care program:  matching the appropriate resources to the specific needs of the patient.

Experienced Palliative Extensivists (PE) — primarily nurses and clinical social workers — are available in virtually every community. These local talent pools represent a natural go-to resource that makes it possible for home-based palliative care programs to be scalable for larger populations. They are equipped with supportive technology, tools, and training required to decrease variability in care, and help to drive positive outcomes.

These experts in caring for patients who are nearing the end of life effectively interact and coordinate care with the designated physicians or other professionals who are responsible for the patient’s ongoing medical care.  This collaborative approach advances care coordination, reduces the cost of care, and results in greater patient/caregiver satisfaction.

Important Role for Palliative Extensivists

The PE team is there to assess the individual’s needs and wishes, develop and implement a palliative care approach, and collaborate with the physician as needed — contacting them for any medication or medical management needs.

The PEs stay connected to patients, learning about their needs and wishes, extending the reach of care and optimizing the role of the physician and hospital case managers. Individuals continue to visit their primary care provider who is maintained as the prescriber and focal part of the care team.

Validating the Model to Avoid Re-admissions

Despite best efforts, a number of patients who are discharged from acute care hospitals are readmitted.

Reducing re-admissions requires an integrated approach – one that involves transition coaching, coordination of services, close communication and coordination among stakeholders, and dedicated technology.

It’s an issue that specialized palliative care teams led by Palliative Extensivists successfully address, as demonstrated by a PIM™ pilot program.

Turn-Key Health PIM Case Study Results

Communications and Cost

Communication across the healthcare continuum and the cost of PHM programs represent two additional factors that hamstring hospitals from tackling these issues in a systematic way. Other critical challenges include:

  • Overcoming rigid mindsets to usher in a new era of payer-provider collaboration
  • Sharing data with physicians who don’t necessarily have the time or the ability to analyze and interpret it
  • Using data to drive patient engagement, change unhealthy behaviors and encourage healthy ones
  • Controlling costs and eliminating waste

Patient satisfaction lies at the heart of overcoming these challenges, and effectively addressing the socioeconomic needs of individuals with serious illnesses, especially as they approach the end-of-life.


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