When it comes to the changing health status of patients after acute episodes and between visits, uncertainty abounds. Until now, care teams have had little to no visibility into the health of their populations, severely limiting their ability to prevent adverse health events before costs spiral.
This week, care management and patient engagement platform RoundingWell released initial insights uncovered from analysis of data gathered directly from patient populations and care teams using the RoundingWell platform over the last 12 months. Data was gathered over the past year at organizations from a diverse mix of patient populations including nephrology, cardiology, diabetes, oncology, and orthopedics, spread across seven states.
Insights revealed the three most prevalent risks for chronic and post-acute patients and three ways care teams are changing the delivery of care:
1. Blood Pressure Management: Risk factors include hypertensive and hypotensive episodes
2. Care Plan Adherence: Risk factors include specific difficulties following care plans, lack of resources needed to follow care plans, and stress and confusion following the care plan
3. Medication Therapy Management: Risk factors include need for thorough medication review and medication planning for palliation
“For so long, actionable data about what happens to patients after hospitalizations and between visits has been too expensive or too difficult to gather,” said Dr. Robert Taylor, RoundingWell chief medical officer. “Now with RoundingWell, care delivery organizations can know what’s actually happening with their populations in near real-time. This opens the door to all sorts of new ways to restructure the delivery of care.”
Three Ways Care Teams are Changing the Delivery of Care
Analysis of the RoundingWell data highlights new ways care teams are taking action to manage patients and their identified health risks. Results show that proactive interventions, asynchronous communication, and standardized care protocols helped address health risks in patient populations.
– Proactive interventions. Care team members proactively intervened on chronic patients long before their next scheduled appointments. RoundingWell significantly decreased the time between a patient’s health status change and clinician intervention. With a typical twice/year appointment schedule, the time between health status change and intervention can be as long as six months. With RoundingWell, the average time between health status change and intervention was 6.5 days.
– Asynchronous communication. Care team members’ efficiency dramatically improved with asynchronous communication. Clinician-to-patient direct messages replaced thousands of manual phone calls. Sending direct messages takes a fraction of the time it takes to make manual phone calls. Direct messages delivered in RoundingWell are read by patients 87% of the time.
– Standardized care protocols. Multidisciplinary care teams worked together to better manage populations. Pathways, standardized care protocols, were implemented for nearly half of all risks identified. Pathways included an average of 12 tasks spanning up to five (5) clinical roles.