Providers add population health management to chronic care equation

The Affordable Care Act (ACA) continues to drive changes in healthcare providers' strategies for treating and managing chronic conditions such as diabetes, obesity and heart failure, according to the Philadelphia Inquirer.

In the past the healthcare system treated such conditions on an episode-by-episode basis, with set Medicare reimbursements regardless of outcome. However, shifts to value-based payments have forced providers to focus on preventive care and early detection for those chronic conditions.

In many cases, this means providers now try to address sociodemographic factors such as food and housing access, tobacco use and substance abuse, and transportation access to manage population health, Steve Carson, vice president of clinical integration at Temple University Health System's Center for Population Health, told the publication.

Temple has allied with other area institutions such as Einstein Health System and the Philadelphia Corporation for Aging on a "bridge coordinator" program. Under this model, social workers connect with high-risk patients before discharge and stay in touch with them after they return home. Readmissions are down 35 percent for patients within the program, according to Carson.

Virtua Health System in Marlton, New Jersey, is exploring similar strategies, identifying high-risk patients and putting them in touch with community care managers, according to the article. Electronic health records are also a valuable tool for managing chronically ill patients due to their value for identifying high-risk patients in general, and which ones require more complex discharge planning, FierceEMR previously reported.

However, despite positive results for individual providers, it's too early to declare such programs a system-wide money-saver, healthcare economist Uwe Reinhardt told the Inquirer. Many primary care providers have been slow or reluctant to adopt formal chronic care management programs, and many have complained the process is more trouble than it's worth.

"The process doesn't work this quickly. We will probably need 10 years to determine its effectiveness," Reinhardt told the Inquirer. "The problem with Americans is we are extremely impatient people and we don't like to hear that some things take a lot longer to know."

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