Healthcare’s Answer to Reaching the Triple Aim

Kristin-StittBy Kristin Stitt, DNP, Consultant, Clinical Strategy at RoundingWell

Healthcare spending in the United States now totals $2.5 trillion a year, the most per capita in the world. Unfortunately, the amount of money spent does not translate into better care, with Americans having poorer health outcomes than other first-world countries.

Care management software sits at an important intersection of patient, community, and health system. Research and experience have resulted in an evolution of thoughts about improving health outcomes, and the patient has continued to be at the center of change.

Healthcare outcomes are driven by multiple factors.  The quality of the care delivered, including the utilization of evidence versus intuition, the accessibility of care, and the affordability of care are just a few.  Probably the most important element, however, is the patient, and the accompanying myriad of behavioral, environmental, and psychosocial factors that make each of us individually unique.

Hypotheses now abound that patient-centered, evidence-based care is rudimentary to health reform. However, consistently defining, and more importantly, operationalizing the concept in daily care delivery is challenging.  The historic “one-size-fits-all, top-down-authoritarian approach” to patient behavior modification has historically been ineffective, and is the antithesis of the now globally recognized term “patient-centered care”. 

In fact, the WHO states that approximately 70 percent of health outcomes are related to these factors and that, until we can influence, understand, and change behavior based on modification of these factors, our costly healthcare efforts will continue to be suboptimal. Understanding the patient contributions (or lack thereof) in achieving evidence-based practice is imperative if we are to pursue an ever-increasing accountability for healthcare outcomes.

This is not a feat for the faint-hearted. Changing behavior is difficult. This difficulty is compounded by the time constraints encountered in the current care delivery system. To effectively assess and alter behavior, health systems will have to find mechanisms to identify, stratify, engage, modify, and measure a patient’s individual characteristics and ensuing behavior as related to health outcomes — all, of course, in the context of being efficient and cost-conscious.

The most promising method to achieve this is via care coordination supported by software specifically built for the task. Coordinated care has been deemed the hallmark of a successful and caring health system, yet quality assessment in this field has lacked actionable, outcome-focused measures.

With the accelerated migration to outcomes-based reimbursement, successful health care systems will need to fully understand how to manage an individual patient’s health and healthcare across the care continuum, engaging the patient as an active, accountable participant in the process. Without an engaged patient, failure is all but guaranteed. 

The care plan serves as the dynamic blueprint to guide this complex process. A robust care plan incorporates a person’s medical and psychosocial needs, evidence-based interventions to address those needs, and a person’s individual preferences and values regarding the goals of proposed treatment plans. It captures the process designed to meet those goals, and assigns accountability along the way. 

For successful care coordination platforms, it includes assessing a patient’s readiness to change, monitoring and measuring a patient’s response to evidence-based treatment, and identifying in real time where break-downs occur. By sharing this information with all members of a care team, a synchronized and organized delivery of evidence-based, patient-centered care is possible.

Robust care coordination software solutions have the potential to become the platform to extend and operationalize evidence based care…from the point of care to a defined patient outcome, capturing not only the treatment plans initiated, but the individual patient choice and response, modifications to accommodate for both factors, and progress toward mutually established goals.

Ultimately, the ability to translate evidence into practice, monitor the practice, and adapt on an individual basis to achieve a defined outcome, will drive improvement in health and healthcare. 

Kristin Stitt is an Advanced Practice Nurse with experience in analytics, system management, implementation science, predictive modeling, and care coordination. After working as an analyst in the airline industry, she migrated to healthcare, serving in a variety of roles in private practice and an integrated ACO, as well as private industry. She recently completed a Doctorate of Nursing Practice in Systems Management at Vanderbilt University, focusing on the utilization of system data and clinical evidence to concurrently guide administrative and clinical decision making in ACO population health initiatives.

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