Population Health Management

To better manage all aspects of health from wellness to complex care, healthcare delivery organizations are increasing their focus on:

• Raising the quality of care
• Improving care coordination across all care settings
• Applying this approach over a much longer period than that of a single episode of care

The population health management (PHM) model goes beyond treating only those patients in need of immediate care; instead it helps physicians assess their entire population and stratify it into various stages across the spectrum of health:

• Those who are well need to stay well by getting preventive tests completed
• Those who have health risks need to change their health behaviors so they don’t develop the conditions they’re at risk for
• Those who have chronic conditions need to prevent further complications by closing care gaps and also working on health behaviors

Overall, population health management strengthens the physician-patient relationship because it provides for numerous opportunities for the care team and the patient to interact. Finally, those patients with the strongest relationships to specific primary care physicians are more likely to receive recommended tests and preventive care.

Using Technology to Strengthen the Physician-Patient Relationship

Technology can be very helpful in assessing and stratifying patients and targeting interventions to the right people. The automation of the processes provides a more efficient and effective way to do population health management and performs much of the routine, time- and labor-intensive work in the background for physicians and their staffs.

There are several IT tools available that can contribute to a stronger physician-patient relationship while lessening the burden on practices:

• Outreach - combines an electronic registry with an automated method of communicating with patients who are overdue for preventive and/or chronic care services. By using evidence-based clinical protocols, the registry can trigger outbound calls or secure online messages to patients who need to make an appointment with their doctor for particular services at specific intervals.
• Care Coordination – Generates actionable reports that help care teams identify gaps in care, better manage chronic conditions and optimize pre- and post-visits.
• Quality Reporting – Uses a sophisticated rules engine that can incorporate disparate types of data with evidence-based guidelines, generating reports that provide many different views of the information. For example, the entire patient population could be filtered by payer, activity center, provider, health condition, and care gaps.
• Patient Education – Provides digital educational materials tailored to patients’ conditions and directs them to appropriate self-help programs.

How Phytel’s Solutions Support Population Health  

Phytel offers an integrated suite of services that strengthens the vital connection between patients and providers, increasing the efficiency of healthcare delivery and improving outcomes. Our solutions allow physicians to follow each patient throughout the entire continuum of care by supporting powerful, coordinated healthcare teams that can engage, motivate and treat every patient at the highest level possible.

Our population health management solutions include:

• Phytel Outreach™ to automatically identify non-compliant patients, notifies them about recommended visits, tests, procedures or follow-up, and tracks the results of your outreach efforts
• Phytel Coordinate™ to automate the care management process and empower care teams to take action
• Phytel Insight™ to improve quality and manage performance by delivering metrics that help practices evaluate their organizational effectiveness in managing their population’s health
• Phytel Engage™ to empower patients to take control of their health through online tools