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Chronic disease and population health management

People with Chronic Disease needs complete care. The current patient experience will be enhanced with the available technology and by figuring out the ageing population and rising incidence of Chronic Diseases.

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Chronic disease and population health management

  1. 1. Smart Technologies in Chronic Disease & Population Health Management The case for outcome-based approaches to better healthcare © 2016 Napier Healthcare. All Rights Reserved. 1
  2. 2. Smart Health Technology Integration Better Chronic Disease Management and Patient Experience © 2014 Napier Healthcare. All Rights Reserved. 2
  3. 3. 3 © 2016 Napier Healthcare. All Rights Reserved. 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 Experience What is to be Done?
  4. 4. 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 Experience A Call for Empathetic Technology © 2014 Napier Healthcare. All Rights Reserved. 4
  5. 5. Enhancing Patient Experience Empathetic Tech-based Options Available © 2014 Napier Healthcare. All Rights Reserved. 5 Technologies provide for the THREE keys to better patient experience: Communication, Access to Information, Doctor/ Patient Relationship  Radio Frequency Identification (RFID) tags o Combined with location aware beacons o Tracks the location of patients moving through the system o Alerts hospital staff of patients’ arrival/presence o Automatically sets environmental controls based on patient preferences  Wearable technology to increase physicians’ face time with patients o Sends AV feeds from patient consultation o Scribe accesses the EHR remotely and enters patient notes o Patient notes are reviewed and signed off by the doctor  Mobile apps, kiosks, portals etc.  Analytics to find at-risk population o Helps people manage their health conditions at home—long before they reach an acute stage o Reduces readmission rates o Uses: remote monitoring devices connected via Bluetooth, a Cloud, digital chart displays
  6. 6. Population Health A Holistic Approach to Chronic Disease Management © 2014 Napier Healthcare. All Rights Reserved. 6
  7. 7. Population Health The Health Outcomes of People in a Community © 2016 Napier Healthcare. All Rights Reserved. 7 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)
  8. 8. Singapore Health Today Ageing Population and Rising Incidence of Chronic Diseases 8 © 2016 Napier Healthcare. All Rights Reserved. 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.
  9. 9. Moving Forward with Accountable Care The Future of Healthcare Delivery is Outcome-Focused © 2014 Napier Healthcare. All Rights Reserved. 9
  10. 10. The Accountable Care Model Based on Accountable Care*, Focused on Outcomes 10 © 2016 Napier Healthcare. All Rights Reserved. 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. 1 2 1 1 1 1 2 * 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.
  11. 11. Napier Healthcare is Ready to Deliver High-Value and Cost-Effective PHM on the National Scale © 2014 Napier Healthcare. All Rights Reserved. 11
  12. 12. The Napier Advantage Enhancing healthcare delivery with an outcome-based model 12 © 2016 Napier Healthcare. All Rights Reserved. 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 + 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
  13. 13. © 2016 Napier Healthcare. All Rights Reserved. 13 APPENDIX
  14. 14. Framework: Population Health Management (PHM) The Continuum of Care and Patient-Centered Interventions © 2016 Napier Healthcare. All Rights Reserved. 14 Source: CareContinuum Alliance, A Population Health Guide for Primary Care Models, 2012
  15. 15. The PHM Workflow Steps in the Provision Model © 2016 Napier Healthcare. All Rights Reserved. 15 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
  16. 16. PHM: Key Components Foundation for Comprehensive Care and Management of Costs © 2016 Napier Healthcare. All Rights Reserved. 16 1. Physicians Provide care consistent with PHM goals 2. Primary Care Physicians/General Practitioners This group enables scalability for larger populations 3. Data Analysis Data is aggregated from EMRs, ePrescriptions, Practice Managers, Payers, HIEs and Labs to be analyzed for actionable outcomes 4. Benefit Program Coordination Financial incentives to be offered for participation in PHM 5. Technology Enables information to be pushed to patients 6. Referral Mechanism Eases the path along the continuum of care between primary and tertiary levels 7. Physician Incentives Ensures involvement at PCP level 8. Replication Ability Applied to community at large
  17. 17. Analytics in PHM Laying the Path to Actionable Insights © 2016 Napier Healthcare. All Rights Reserved. 17 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
  18. 18. Technology Adoption in Healthcare The Factors Influencing IT Investments © 2016 Napier Healthcare. All Rights Reserved. 18 Source: Technology in the NHS— Transforming the Patient’s Experience of Care
  19. 19. THANK YOU w w w. n a p i e r h e a l t h c a r e . c o m i n f o @ n a p i e r h e a l t h c a r e . c o m 19 © 2016 Napier Healthcare. All Rights Reserved.