Value-Based Care Software to Support Your Population Health Strategy

Using Value-Based Care Software to Support Your Population Health Strategy

This is the fifth blog in a series of five from Dr. Jon Hart on value-based care.

The three foundational elements of Population Health Management are risk stratification, plan of care and longitudinal support as we discussed in my series on value-based care. To successfully create value in healthcare for our patients and providers, we must be disciplined to practice these fundamentals. The primary catalysts for this success are communication and collaboration across the entire team managing a patient’s care, regardless of location on the healthcare continuum. 

To meet the communication needs of the care team, technology and value-based care software can offer solutions to advance our efforts. As described in the blog on Longitudinal Support, an ideal tool to communicate a plan of care would be secure, electronic, up-to-date, potentially asynchronous, and would be accessible to the whole team.

Value-Based Care Software Can Connect All Care Providers 

Most would agree that patients who spend time in a Skilled Nursing Facility (SNF, aka “Nursing Home”) after a hospitalization are at high risk for adverse events, including readmission to the hospital. We don’t need an innovative predictive analytics tool to discern that fact. 

Likewise, these patients generally have complex plans of care with many moving parts and multiple medical professionals on an Interdisciplinary Team (IDT) involved in their journey to optimized health. Add to this a plan to (hopefully) discharge them soon from the SNF and transition to home, and we have created a scenario with tremendous potential for disconnected “care” leading to adverse patient events (like returns to the ED or readmissions to the hospital). Olio, a software solution for value-based care teams, mitigates many of these issues.

In the setting of a patient’s post-acute health needs requiring skilled nursing in a facility, the IDT must be fully aware of the plan of care when the patient leaves the hospital and arrives at the SNF. For the IDT members outside the SNF, something as simple as not knowing where the patient is (ie., which SNF) can be an obstacle to their visibility of the patient and their active participation in the plan. 

With Olio, providers managing a patient’s plan of care have full visibility into where the patient is receiving care once they leave the hospital, and they get updates from SNFs and home health care teams so they know if the patient is trending in the right direction and can intervene when appropriate. This is a good step in the right direction, and the Olio tool builds upon that foundation.

Value-Based Care Technology Helps Hospital System Reduce Readmissions

I reached out to Deaconess Health, a top 5 NextGen ACO, in Southern Indiana to learn more about how they were using the Olio tool in the post-acute care space. I’d heard of some success they were having in decreasing hospital readmissions from SNFs, and the population health team credited the use of the Olio tool with that success. The largest benefit they’ve seen with this platform is its ability to function as a secure engagement tool that allows the care teams of the ACO and the SNFs to digitally connect. 

In addition to informing Deaconess where the patient is (which SNF), Olio provides the ability for them to receive a daily report on all their patients and their status. This function not only enables the entire team to know and manage the length of stay for the patient, but also keeps everyone updated as to the patient’s progress in rehabilitation, leading to anticipation of their next needs. According to the Deaconess representative I spoke to, Olio’s digital software replaced most of the phone messages and emails for communication. The chasm carved out by disparate electronic health records was bridged through Olio. 

Plans don’t always proceed without complication and patients sometimes have setbacks. One of the most valuable capabilities of Olio, based on my Deaconess conversation, is the ability of the SNF to quickly escalate information or an issue in order to engage the appropriate team member for assistance. 

This rapid, bidirectional communication tool is enhanced by Olio’s ability to function on mobile devices in addition to PCs, so providers could be alerted to progress and problems while they are on the go. In a short message of what’s going on with a patient and why, a SNF can communicate with the external care team in order to engage interventions to avoid worsening of conditions leading to returns to the ED or readmissions to the hospital. 

Since these escalations are flagged, time-sensitive, and in discrete fields, reporting and analysis is possible. Deaconess has reported an astounding decrease in hospital readmissions from SNFs, and they credit this bidirectional communication component of the Olio tool with most of that success. (I would add that the success can only occur when all the stakeholders engage in the platform. The ease of use and ability to improve their patients’ care, though, seems to be enough incentive for all to actively participate.)

Digital, Real-Time Communication Closes Gaps Across Transitions in Care

The ability to communicate quickly for changes in status or needs allows the IDT to be responsive to the patient’s changing needs. Reliable communication of medication issues affecting physical therapy, poor rehab progress, or potential complicating conditions allows for dynamic and rapid changes to the plan of care, avoiding complications and heading off potential setbacks early in their course. 

Other, less urgent messages can also be shared with the care team to ease a patient’s transition to home. If it becomes apparent that the patient will have some unforeseen needs at home – like durable medical equipment, assistive devices, continued medical treatments – the SNF can alert the IDT so these changes in the plan of care can be assimilated and acted on. 

Daily updates also help keep the SNF discharge date from being a surprise, allowing for followup visits in the home or in the physician’s office to be arranged, all the while, smoothing the transition from SNF to home and closing gaps patients often fall through in this process. 

The best plan of care on the appropriate patient goes nowhere if the support, communication, and coordination is not longitudinal and adaptable, guiding the patient on the path to wellness. Technology solutions can help you provide appropriate communication of the plan and needs for changes in the plan to support at-risk patients in SNFs, while improving quality care, decreasing cost, and improving experience. In other words, technology can help you create value in healthcare.

More Articles in this Value-Based Care Blog Series by Dr. Jon Hart:

Creating a Value-Based Care Model

Risk Stratification for Population Health Management Teams

Valuing Patients with an Individual Plan of Care

Building Better Relationships Key to Value-Based Healthcare Delivery

Dr. Hart is a Board-Certified Family Medicine physician with over 20 years of clinical patient care experience creating a foundation for his over 11 years of experience as a healthcare executive.  He has practiced as a rural Family Physician, ED Physician and Hospitalist. Administrative experience includes CMO of payers and executive positions in hospital health systems, building and running value-based systems. Currently, Dr. Hart serves as the Medical Director of Value-based Programs for Millennium Physician Group in Florida. Visit his website: