Cardiovascular disease (CVD) is the leading cause of death in the United States. In fact, 121.5 million, or nearly half of American adults, are living with CVD. Improving the clinical outcomes for these patients is essential to saving lives and enhancing the healthcare system. Better outcomes for this patient group can be achieved through population health management.
Population health management refers to the process of improving clinical health outcomes of a defined group of individuals through improved care coordination, patient engagement, and preventative care measures, according to the American Hospital Association. It encompasses care models, programs, and strategies needed to improve cardiovascular outcomes. Below, we outline a few tactics that can benefit your practice and cardiac patient population.
The risk of developing heart disease or worsening it can rise if patients avoid office visits and don’t have access to resources to manage it. Implementing RPM can help. Discover how in this infographic.
Successful population health programs focus on the results. The American Heart Association released a statement recommending healthcare systems prioritize “a set of clinical measures to evaluate before, during, and after the intervention” for vulnerable populations. Specific outcomes can guide a program in which processes develop to achieve those set outcomes.
For example, if a practice wants decreased hospitalizations related to heart failure or a decrease in blood pressure or cholesterol levels within their patient population, then that is their goal outcome. They can use those identified clinical measures to build the framework of the program that will achieve those results in the most effective and sustainable means necessary.
After the outcomes are determined, eligible patients must be identified next. The foundational step to targeting patients is by organizing patient populations into high-risk, low-risk, and the ever-important rising-risk groups. Known as risk stratification, it is the process of identifying population needs across all levels of risk and designing the appropriate interventions needed for them.
When it comes to assessing a cardiac patient population, the key is to evaluate patients’ risk of developing CVD or their risks of experiencing complications due to CVD, according to research published by StatPearls. Risk factors to consider include high blood pressure, high cholesterol, age, and other chronic conditions such as diabetes. These factors increase the risk of heart disease and can complicate the health of patients already diagnosed with CVD.
Cardiovascular risk can be assessed through several different risk models accounting for those different factors. While no single model is superior to the other, the goal is to find the evaluation that best produces data for the patient population. Therefore, data can be used for healthcare management and decision making by finding the right patients and giving them the care that they need.
With the right patient population, they will need a population health program that works for them. Implementing the right program depends on the type of data collected. Data needs to be as complete and accurate as possible to detect health concerns and trends within a population faster.
Providers and care teams who have access to timely, accurate and consistent clinical data can receive a more comprehensive view of their patients’ health progress. It allows them to intervene sooner on the patients’ behalf and deliver better valued-based care. This can lead to an improved quality of care and lead to improved patient outcomes.
New technology tools are enabling vast amounts of information to be collected. For example, Remote Patient Monitoring (RPM) provides real-time data of patients’ vitals in between office visits and has been found to improve cardiovascular outcomes.
The American Heart Association published a study that showed patients using RPM saw an average decrease of 4.7 mmHg in systolic blood pressure and a 1 mmHg decrease in diastolic blood pressure. RPM has also decreased hospitalizations due to heart failure by 33% in another study done by Lancet.
RPM readings have proven to significantly reduce blood pressure, decrease hospitalizations and give data insights that allow providers to intervene sooner and provide better care.
Building and identifying the right programs to achieve those clinical outcomes should focus on empowering patients to become partners in their own healthcare. Patients who feel more engaged to take part in their healthcare decisions through self-management have been found to have better health outcomes, according to a Stanford University study.
When patients feel more motivated and supported by their care teams, they are more likely to practice preventative measures and self-management. Care management programs such as Principal Care Management (PCM) and Chronic Care Management (CCM) provide patients with consistent interactions that keep them engaged and teach them how to manage their health.
For example, at Wellbox, our CCM program has a patient engagement rate of 85%+. Patients who are enrolled in the program have shown to take active management in their health, develop relationships with their care team, and achieve the following outcomes:
These touchpoints that care management programs provide can also lead to improved outcomes for cardiovascular health. According to a Commonwealth Fund study, they found that patients enrolled in a CCM program reduced their readmission rate to the hospital due to heart failure by up to 30%. Keeping patients engaged in their healthcare decisions makes for a stronger program and better outcomes.
A factor to consider when it comes to population health is if patients have access to care. According to the Medical Economics Journal, one of the most common reasons a patient “fails to follow a doctor’s treatment plan or fails to take prescribed medicine is social determinants of health.”
Some patients lack the resources or access to care because of where they live, or they are experiencing a provider shortage. When they cannot access healthcare services, it should be brought to them through services like virtual care solutions. The implementation of virtual care like RPM, PCM, and CCM can reduce the barriers to care that some patients face. These programs can monitor patients while they are at home and provide them with additional care services in between regular office visits.
For example, a BMJ study found that patients at high risk of CVD saw improved outcomes after utilizing virtual services. Outcomes included improvements in diet, physical activity, drug adherence, satisfaction with access to care, treatment received, and care coordination. The virtual care services they received increased their access to care and allowed them to receive additional support for their health.
The American Heart Association released a statement recommending the use of virtual care services for improving cardiovascular outcomes. They said that virtual care solutions can reduce “many widespread disparities in access to care, particularly those attributable to geography or provider shortages,” according to the AHA Journal.
There is no one size fits all for population health programs. Every patient is different and even every cardiac patient will have different needs when it comes to their cardiovascular health. In fact, a report published by Abbott claims that patients want more personalized care by including more interactions and establishing more of a consultive relationship with their care teams. The report also says patients see value in giving physicians access to relevant data and want physicians to monitor patient progress remotely when necessary.
This is when RPM or a care management program can be useful. These programs personalize every patient interaction and make sure patients get the care that they need.
With RPM, cardiac patients can have their blood pressure or blood glucose carefully monitored with live transmissions of data. If any vital rises to a concerning level, the information will be relayed back to the provider, and they can take the necessary measures to help the patient. The more personalized monitoring that patients receive, the sooner providers can act in preventing further issues or complications.
Patient interactions can become very personalized through care management programs as well. When patients are enrolled in a PCM or CCM program, they are assigned a care coordinator that develops an individual care plan and works with them to achieve their health goals. This lets practices work more closely with their high-risk patients and ensure they are managing their conditions well in between office visits. It is also helpful when working with cardiac patients in lowering their blood pressure or cholesterol and keeping them out of the hospital and emergency rooms because of heart failure.
Cardiovascular disease is one of the greatest chronic conditions affecting the United States. Improving these outcomes will not happen overnight but they can advance. It can begin with a few population health tactics that focus on the most at-risk patients and providing them with the right care.
If you would like to find out more about how population health management can improve your cardiovascular outcomes, contact us today to learn more.