Clinical data has and will continue to set the foundation for care quality improvements. The data, however, that informs patient-specific risk assessments—readmission, attendance and likelihood of payment—is nowhere to be found within the confines of a hospital. Integrating external data now becomes essential but obtaining this data can be challenging. It’s high time providers be able to understand patients beyond looking at clinical encounters. By tapping into this underutilized source, the path to improving outcomes become more evident.
While there are many definitions of population health or the “health outcomes of a group of people”, the terms place emphasis on the determinants of health and the interventions to elevate overall health status. Population health is often used interchangeably with public health to describe the activities conducted by governmental public health agencies, community and national organizations to improve the health of a community.
It’s no secret that the shift to value-based is leading more physicians and nurses to be employed by hospitals. Patients feel the height of these effects because Medicare reimbursement rates have not yet kept pace with inflation. So how can physicians and nursing facilities manage their bottom line while losing money caring for this growing group of patients? Some will simply take care of fewer patients, which will reduce overall revenue in an effort to minimize the financial impact. However, there are things doctors and nurses can do to balance out the loss and actually improve margins during the slow transition to value-based care.
Improving population health begins with focusing on the health of each one of your patients. To do so, we in the healthcare community—nurses and physicians alike, need to identify and engage patients—particularly those of high risk—throughout the continuum of care. These are individuals most likely to be readmitted, miss an appointment, skip medications or unable to pay their bill.