Optimizing Care Delivery – Closing Gaps

Transcript

This gives you an overview of our longitudinal service offering, which we consider part of it because it uses a little bit of all the services that we have to offer in organizations. So that performance oversight, where we’re looking at your population health data, we’re telling you who has the care gaps. We review the charts to make sure that the care setting and the evidence-based care plan closes the gap. We appropriately identify, document, and ensure that the PCP has all the information they need to get that evidence-based care, including an appropriate screening, which is really important for care delivery.

So, one of the things that can happen is, we have experts who give the pre-appointment guidance. The patient may have some objections, or they may have started taking a medication or have concerns about the results of a screening.

You know, that’s where an eConsult might come in or a telehealth visit. So they can provide recommendations. To the care team, that’s the most common way. We follow up because the PCPs are busy. But, you know, they can act in alignment with the PCP, yes. So that if the PCP has had the conversation, the care gap still remains open. And there are patient objections or patient symptoms or concerns that we’re routing that patient to the next best, convenient, and appropriate setting. And that’s where care support comes in. So, and that, and that situation, if it is a telehealth visit, we can help navigate if there’s communication with a specialist or an in-person specialist, whether it’s their current or a referral to one. We can help make sure that that information comes back to the PCP, that the care gap was closed, and the nature of that closure.

Yeah, that’s why step five is so important from our perspective, because the PCP really should be at the center of care. Yes, and the monitoring continues. You know, Xanthe has brought this up, but even though we see SUPD gaps open and close and then reopen, we are, her team is always making sure that they close again wherever possible. And that often is because there has been an issue, like with the patient’s compliance. In other cases, it can be an issue with social determinants of health. You know, they lack transportation or they can’t afford the copay or some other mitigating circumstances that are preventing them from being compliant with the PCP’s recommendations. So we support that as well. Here again, this is where that non-compliant patient we’re coming in with a strategy, not with a reminder.

You know, we don’t want the PCP to be left on their own. We want to say, “Hey, here’s what we see in the data. Here’s what the patient did, here’s what they haven’t done, here’s the next steps.” Here are some options that you have. In terms of redirecting the patient to get them, give them the confidence that they’re on the appropriate treatment plan. Because there are situations where a patient says, “Well, I’m not comfortable with that. I want to go out and see a specialist.” That’s great. We can help facilitate that and again, make sure that that documentation is done appropriately. So the care gap closes on the PCP, who is carrying the financial burden for that patient? I mean, I think that’s particularly important. Again, so that’s where the care delivery might get routed in. We’re going to confirm that the care gap is closed, stays closed, and then, you know, we’re reporting back ongoing. But ideally, you’re going to get that full-year summary as well as did this program, and yes, it will impact care gap closure. What was my return on investment and did it improve my patient outcomes? And that’s what we’d like to demonstrate at the end of the year. But obviously, we get leading indicators of that as we see the care gaps close early in the year. And we see that impact ongoing.