How to Build a Successful Population Health Strategy with Technology?

Access for care management teams to LTCF (Long Term Care Facility) EMRs through patient portals or other programs are important for patient management beyond the hospital walls.
Remote patient monitoring (RPM) is a new method of management that we are slowly moving into in regards to population health. Thus far, we have found that the additional spending on continuous glucose monitors has been a good investment. The patients enrolled in continuous glucose monitoring (CGM) are being monitored by a care team and are much more compliant because they test their blood sugar, on average, 4x more a day.
Texting platforms are extremely important for a successful care management program. Most commercial plans have members that prefer this mode of communication, so a sound texting platform or patient portal with these capabilities is key to finding and engaging patients.
A population health program with claims-based data and social determinants of health (SDOH) information is key to identifying patients that are most in need of care management services.
A social determinant of health tool to help with closed-loop referrals is a new tool that we recently put in place. This allows us to track our referrals and ensure pts receive services.
Health information exchange data that allows care teams to identify patients discharged from external facilities is pivotal in population health.

Contacting patients can be difficult. Patients often do not answer their phones and do not understand why their healthcare provider is calling them unless they had a recent visit. Therefore, we are in the process of putting a texting platform in place to help with the patient connection.
Care managing patients in long-term care has always been difficult. Over the last two years, we partnered with a vendor that provided us with a dashboard into Point Click Care which is the most widely used EMR in Arkansas. Moving into the rest of 2022, we are partnering directly with a local LTCF Clinically Integrated Network to access this information. Our care management team will work alongside their liaisons to better manage our populations.
Palliative care has always been a struggle for us, so we created an in-home Palliative care program in 2021. This program allows us to improve the quality of life for these patients, obtain advanced directives for these patients, and help the family better understand the process that their loved one is going through.

A well-rounded population health team (RN care managers, Pharmacists, Social Navigators, Pharmacy Techs, Behavioral Health Specialists, Outreach Specialists)
A robust analytics tool allows team to identify patients through mechanisms other than just discharge.
A population health platform within the EMR integrates with the physicians for seamless care.
Physician engagement at all levels. Must have the ability to communicate with the providers regularly and provide them with the support they need to improve their quality of care.