How provider organizations can find and reconnect with patients who have fallen out of their care.
To succeed in a healthcare system intent on shifting from a transactional, volume based model to a more value-based, longitudinal approach, providers are adapting their practices to accept alternative payment models and engage patients in proactive health management. One problem with this approach is that they are still missing a critical subsection of patients – those that are not engaged with the system at all. We call these “disconnected patients.”
Who is the disconnected patient?
- Lost touch – The ones who have lost contact with their providers, or who are no longer able to or interested in visiting their provider on a regular basis, which means there is no ongoing relationship with a primary care physician. The Kaiser Family Foundation 2013-15 survey results estimates that 17% of women and 28% of men did not have a primary care physician, and many of these reported they were in poor health.
- Effectively homebound – The ones unable to visit a physician due to financial, health or socio-economic reasons, like poor access to nutrition, housing or transportation. Patients in poor health who are disconnected from the healthcare system tend to need high-cost hospitalizations when a health crisis arises. In fact, a recent study estimates that homebound patients are 3 times more likely to be hospitalized within a 12-month period than the non-homebound. For providers in value-based contracts, these high-cost interventions can offset the financial impact of effective care and cost management for hundreds of other patients, resulting in underperformance in these contracts. So it is all the more important to get in front of these issues before they arise.
What to do about disconnected patients?
For providers, disconnected patients pose two challenges: 1) how to identify them, and 2) how to engage them in ongoing care, preferably preventive. This involves finding these patients, updating their health information, truly understanding why they are absent from care, and taking steps to tackle those obstacles. Successful approaches include:
- New Visit Types – Annual Wellness Visits create an opportunity to reconnect with patients gather information about the state of their health (which can create significant value via risk adjustment), and offer other screening or preventive care as needed.
- Care Management – Engaging specific patients in ongoing care can help manage their chronic conditions and comorbidities, and reduce hospitalizations.
- Home-Based Care – By bringing care to the patient’s home, providers deliver care to patients where they are best served. This includes services such as on-site care management and medication management, coordination with community and social programs, and proactive care for chronic conditions. Extending their reach into the patients’ home also fosters a stronger relationship, increasing the likelihood that patients will reach out to their providers before availing themselves of more costly emergency care options. The reduction in travel back and forth to appointments reduces stress on patients and caregivers, offers better and more coordinated access to the healthcare system, and maintains engagement. Finally, home-based services can help identify gaps in social determinants of health, and can coordinate community support programs like transportation to specialist appointments and meal-delivery to address these gaps.
- Community Programs – The ability to create comprehensive care programs like the PACE program (Programs of All-Inclusive Care for the Elderly) can meet the end-to-end needs of vulnerable patient populations. Although currently focused on narrowly defined group of certain frail, community-dwelling dual-eligible (Medicare and Medicaid) elderly patients, the effectiveness of this kind of program provides a model for broader application to other populations.
New times call for a new approach to disconnected patients. They have long posed a challenge for providers, but become more important than ever as we shift toward value-based care. A well-designed program to extend primary care services to strengthen the provider’s reach within their patient base, can represent a significant opportunity to find and repatriate disconnected patients, and most importantly, to keep them engaged in their care.