Paving the Way Towards Integrated Care

Dr Joel Ratnasothy, MD, Medical Director EMEA, Caradigm examines how population health data could help drive step-change towards integrated care.

London, 12 November 2014: The fundamental driver of integrated care is the need to move away from reactive treatment cycles of episodic care to a world where stakeholders are able to analyse, predict and ultimately prevent avoidable disease. Prevention is, after all, better and cheaper than cure.

The challenge is to build a system that gets to the ‘person’ before they become the ‘patient’ – and the downstream benefits of efficiency and outcome gains will naturally follow. It’s a futuristic vision – but in the here and now, commissioners are already being asked to commission services across the whole care continuum. Unequivocally, they need tools to help them do it.

Data is Fundamental

Data, and access to it, is fundamental. Without the complete picture of an individual patient, it can be difficult for clinicians to deliver optimal care. Without the complete picture of all their patients – from demographics, to care pathways and prevalent LTCs or comorbidities, for example - a commissioner may not be able to conduct meaningful retrospective or predictive analysis to ensure that resources are appropriately aligned.

A potential first step therefore, could be for NHS organisations to introduce solutions that allow them to capture and optimise critical population data. With the right tools, stakeholders can be better supported to coordinate care and transform service delivery more effectively.

Understand Patient Demographics

The optimal use of informatics and analytics tools can empower stakeholders with cross-boundary intelligence on population health. Who are the high-risk patients that generate the majority of healthcare costs, for example? Or indeed, who might the low-risk patients of today be that may become high-risk patients tomorrow?

With this type of insight, organisations could better understand patient demographics and establish areas where integrating care can help to improve outcomes and drive disease prevention. In the process, stakeholders could use such insights to improve clinical outcomes, maintain population health and drive down utilisation costs.

Identifiable Population Health Needs

Moreover, such tools provide management information that can help align the workforce and optimise resources. By enabling organisations to identify, assess and stratify patient cohorts, smart informatics could support workforce planning and give senior management crucial operational data and performance metrics to measure effectiveness. Predictive analytics may mean that future resourcing models are proactively aligned to identifiable population health needs.

Securing access to meaningful population health data, and then using it to ensure clinical teams deliver the appropriate care to patients through effective coordination, is an approach that really could help the NHS meet its current objectives of high-quality, efficient healthcare – and pave the way towards integrated care.

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