A Client Health Management Strategy for Long Term Care Organizations


1503.m00.i124.n006.s.c10.medicine-icons-on-background-with-text-300x200.jpg (300×200)
This means developing custom, patient centered health care strategies that are based on predictive analytics and thoughtful individualized outreach and support programs.

Dr. Cathleen V. Carr, ED CertifiedCare.org


PHM – Strategy for Long Term Best Care Practices for Treating the Aged

PHM, Patient Health Management (or Population Health Management) is one of the most promising avenues for agencies and hospitals to thrive in the environment of health care reform. It entails identifying high-risk clients / patients and determining which ones require individualized attention.

This means developing custom, patient centered health care strategies that are based on predictive analytics and thoughtful individualized outreach and support programs.

PHM is the aggregation of patient data across multiple health information technology resources.  It relies on a care coordinator, the person who works closely with patients, their family caregivers, licensed Home Health care aide, primary care physician, physical / other therapist(s), and others participating in their care and well-being, whose goal is to foster communication, improve individual well-being and enhance outcomes on all levels.


PHM improves quality of care and lowers cost by identifying individual patients  who are most likely to benefit from intervention to proactively enable better care. For example, patients who are at high risk for hospitalization benefit from PHM strategies to manage transitions of care, such as hospital discharge, to support the whole patient and prevent unnecessary readmission by matching patients with an appropriate care team of primary care physicians and specialists who are focused on both treatment and prevention.

PHM helps to identify problems early on can significantly reduce cost by preventing the need for expensive tests or future hospitalization, ensuring physician engagement with evidence-based care plans to reduce variation and inefficient or costly approaches to care.

In-house benefits of PHM  are tied to effectively managing a provider network to identify opportunities for cost improvement, such as in the areas of pharmacy, imaging, and network leakage. PHM can foster organic quality improvement through identification and closure of evidence-based gaps in patient care while providing transparency to quality compliance on a real-time basis to make adjustments as needed.

Activating Predictive Analytics

The health care industry has begun to adopt predictive analytics as a prerequisite for PHM and an important component of any approach to reducing the total cost of care. Predictive analytics put data analysis into a single, actionable patient record, enabling the care team to take actions that lead to better clinical and financial outcomes. These statistical tools are also being used to forecast which patients are likely to be at increased risk for health problems and cost more health care dollars. Some health care organizations also apply predictive analytics to large clinical and administrative data sets in an effort to identify higher-risk patients and intervene before they become seriously ill.

Quality-Improvement.png (750×563)

To be effective, however, stakeholders must develop the infrastructure and culture required to turn the data into action. They must have the ability to generate timely reports and use automation tools to apply intervention strategies across a patient population. Predictive analytics shines a light on the top percentage of covered lives that are at highest risk for illness and increased costs. These are the patients who will most likely benefit from PHM programs designed to improve their health and lower costs overall.1

This level of state-of-the-art health analysis technology enables users to confidentially assess the health risks of every patient. When risks are identified and need attention, these programs can coordinate personalized guidance for the individuals who need it the most. Having the ability to provide a suite of industry-leading health advocacy services can greatly improve patients’ health and keep health care costs contained.2

Individualized Outreach Programs

The goal of an individualized outreach program is to develop a healthier person over time. The program should be designed to evaluate the overall health of your clients and identify clients who have common and costly chronic health conditions or who are at risk of developing them.

Get affordable, accredited, comprehensive caregiver education conveniently online only at CertifiedCare.org


Develop a program that helps them improve their health from the point of intake. The program should have the capacity to analyze collected health data — such as emergency room visits, hospital admissions, and pharmacy claims — to identify plan participants who have or may develop chronic health conditions such as hypertension, diabetes, or certain cancers.

Upon enrolling in the program, participants should have access to a registered nurse after completing a comprehensive health assessment. From there, customized care plans can be developed to achieve individual health care goals and optimize participants’ involvement in managing their chronic conditions. Patients are then stratified according to predetermined metrics.

In addition, nurses can efficiently manage the identified at risk clients through telephone/technology/and traditional on-site outreach. By doing so, nurses can give properly trained care aides and patients education, support, and recommend tools they need to better handle their own health.

social work icon.png (200×216)

It’s important for clients to have a contact they can reach out to with questions, concerns, and choices regarding their health. Agency nurses can fulfill this role and also work with providers to:

  • assist with provision of skills for self-care
  • provide and reinforce patient education
  • improve patient satisfaction
  • improve quality of care
  • improve patient contact
  • increase compliance with treatment
  • improve knowledge and professionalism
  • improve patient quality of life


To be effective, health care organizations must focus on high-risk patients who generate the majority of health costs. They must also pay attention to the preventive and chronic care needs of every patient, all of which makes access to transparent health data crucial.

Recruitment-Metrics.jpg (300×300)

Tracking health care data can serve as the foundation for quality improvements and changes in clinical behaviors. Transparent health care data is vital for curbing costs and changing patients’ behavior patterns. In fact, data analysis serves as the backbone of wellness and PHM strategies, and leads to greater efficiency and effectiveness.  A properly trained Certified Personal Care Aide, meaning one who has been tested and registered by CertifiedCare.org, can assist with this data aggregation in the field at less cost than a RN.

For providers, transparent health data provides:

  • Standard metrics for assessing quality of care
  • Outcome- or performance-based payment
  • Reduced paperwork
  • Knowledge of prices paid to hospitals, labs, and specialists to inform patients

Reducing costly future medical care leads organizations’ health care costs to go down while patient health improves, making this approach a win-win for stakeholders.


As elder and chronic care shifts toward value-based payment models that compensate physicians based on patient care and outcomes rather than frequency of services, quality becomes paramount. Under traditional fee-for-service payment models, there was no real incentive for providers to reduce unnecessary care.

In PHM, the objective is to minimize costly, yet often unnecessary or redundant, interventions.

A PHM plan that is patient-centric, involves predictive modeling, and includes individualized outreach programs — all built upon a foundation of transparent data — will become the standard. 3

Predictive analytics allows users to assemble all of their patients’ health data, including past claims and medical records, and process it through a comprehensive health analysis system. The system identifies patients who are at highest risk for serious health issues, so providers can make a suite of proactive health advocacy services available immediately.

Data that measures health care prices and quality can serve to demonstrate value, treatment outcomes, and level of access. In particular, a well-coordinated PHM program for the aged depends upon such information to lower the total cost of care. Strategies designed to optimize this opportunity have potential to help close the gap between the high rate of U.S. health care spending and current levels of quality and access.

The prevalence of multiple chronic conditions and functional impairment within the aging population is on the rise. There’s more need than ever for a level of coordination that improves outcomes and lowers the total cost of care. Successful health care and long-term service delivery models must involve a team of providers to meet individual needs, increase access to health care, improve outcomes, and synchronize the various services and supports.

Edited by Dr. Cathleen V. Carr, ED CertifiedCare.org

Footnotes and Reference Sources:

  1. Caring 2014 Population Health Management by J. Barerdo
  2. Ibid
  3. Ibid







About Elder Care Advice blog

Get professional elder care giving advice, advocacy, education and tips for those who care for and about the frail elderly at the ElderCareAdvice blog. We are generously sponsored by CertifiedCare.org. Most posts are written by Cathleen V. Carr, unless attributed otherwise. We welcome relevant submissions. Submit your article and by-line for publishing consideration (no promises!) to Havi at zvardit@yahoo.com, our own editor who will ensure submissions are given the best possible treatment and polish before publication, ensuring a professional level of publication. There is a nominal service fee involved ($45). Allow up to 30 days for publishing.
This entry was posted in Aging at home, Elder Care, Holistic Eldercare, Professional Eldercare, Senior Care Auditing, Special Needs and tagged , , , , , , , , , , , . Bookmark the permalink.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s