Emcara Health

Mark Cohen

As our population ages and grows sicker, we must change the way we administer population health strategies, specifically when it comes to the delivery of primary care. Extending the impact of community-based physicians while also offering ongoing support for high-risk patients is imperative for improving outcomes while curbing costs. In today’s reality, we have lines of patients overwhelming emergency rooms. Too commonly, patients wait for two hours in an ambulance just to get into the ER. For many of these patients, the ER is not the right care venue, and for those who actually have urgent needs, a dose of proactive and preventive support might have made all the difference.

By delivering more comprehensive and consistent support via in-home care services, we can change the trajectory for patients who are medically complex, vulnerable and underserved. Combining monthly visits to home with 24/7 availability for inbound requests can result in a positive impact on their health and quality of life. Of course, this care must be tightly coordinated with each patient’s primary care provider and key specialists, while at the same time filling holes and bridging gaps that exist in the system.

Health plans have largely embraced the idea of shifting more care to the home and bolstering the support that high-risk patients receive. However, it hasn’t been easy for them to determine the right formula for success. In this article, we will briefly explore three key ingredients. You need the right data, the right team and the right tech to make this work.

The Right Data

Being able to use data to fuel home-based care delivery for a population is a major deal. It’s critical to understand what is driving admissions, what happened with patients who were seen in the ER or admitted to the hospital, and how many patients are effectively following discharge orders. Looking for gaps, searching for trends, and continuously improving should be hallmarks of any analytics strategy. This becomes even more true as health plans enter more deeply into value-based models that require another level of sophistication in terms of leveraging data to deliver better, more personalized care

As an example, the most common drivers of emergency room visits and hospitalizations are largely avoidable if the right support is provided in a timely fashion. What we see in the data is that congestive heart failure, chronic obstructive pulmonary disease (COPD), pneumonia, uncontrolled hypertension, and diabetes are often the culprits for unnecessary healthcare utilization. Many patients managing these conditions fall through the cracks. If they received more support on a regular basis, we could achieve much different outcomes for them. Again, this starts with having the right data and being able to turn it into actionable insights.

The Right Team

Caring for a patient holistically, including physical, mental and social needs, requires a multidisciplinary care team that integrates physicians, nurses, behavioral health specialists, pharmacists, and community health workers. This team can work together to deliver comprehensive and coordinated care for individuals.

In many cases, the major barriers to better health for individuals have little to do with their physical condition. Social Determinants of Health (SDoH) are a significant part of the story for many patients. These barriers could include education, financial constraints, and transportation challenges to name a few. In some cases, addressing these social concerns can be very simple.

As an example, we were working with a patient who was not showing up for scheduled visits but not telling her doctors why. In the end, it was because she didn’t have an effective way to navigate the steps at her front door. Our care team was able to find a volunteer organization to build a ramp for the patient at no cost and remove this barrier.

The Right Tech

We live in a time where X-Ray machines can literally walk up steps, roll into a patient’s home and within four hours we have a reading that we can evaluate. From blood pressure monitoring kits to blood oxygen readers, there is a lot we can do to support patients remotely through the use of technology. But it has to be the right approach to technology, which includes proper training and support for both the patient and the care team.

Telehealth is a great example of a technology that offers great promise but also pitfalls. The problem with telehealth is that many older, sicker patients can’t effectively complete a telehealth visit on their own. They need assistance. Back to the multi-disciplinary team, a nurse or a community health worker can assist patients in participating in a telehealth visit. They can also send photos or videos back to the primary care physician to support a virtual consultation of a healthcare issue.

 Case in Point

We recently made an in-home visit for a patient who was on oxygen, nursing a wound on his leg and struggling with a cough for four days. Upon examination, it was obvious the patient had pneumonia. We were able to get him on antibiotics, coordinate with his primary care physician and follow up with him a few days later to ensure his condition was improving. Not only were we able to prevent an ER visit and potential hospitalization, we were able to bring relief to the patient and his family in a timely manner. This visit reduced healthcare costs for the individual’s health plan and improved his experience and confidence with his healthcare team. It’s one of countless examples where we have seen the power of leveraging the right data, the right team, and the right tech to deliver quality, coordinated primary care to wherever a patient calls home.