The goal of value-based care (VBC) is to create financial incentives for providers to improve patient outcomes while controlling costs of care. Unlike the traditional “fee for service” (FFS) model, under which providers are reimbursed based on volume, VBC rewards providers for efficiently delivering higher-quality care.

While greater operational efficiency and cost control are essential to the success of VBC initiatives, so too is patient engagement. Care coordination and care management are far more difficult – and far less likely to achieve optimal outcomes – without patients who are fully engaged with their providers.

Most patient engagement initiatives focus first on improving provider understanding of patient status. This involves stratifying a patient population to identify pockets of disease and the people with one chronic disease or more (polychronic). Once stratification is completed and these chronic/polychronic individuals are identified, providers can look at ways to educate them about managing their conditions and conduct outreach to offer care opportunities.

Assessing capacity for patient self-care

In addition to clinical markers, risk stratification should consider patients’ abilities to both manage their health and navigate the healthcare system. A Patient Activation Measure (PAM) that scores individuals from 0 to 100 can be used to identify people who could most benefit from a care intervention. Individual PAM scores are categorized into four levels of activation, from low (1) to high (4), according to the American College of Physicians (ACP). Patients in Level 1 are considered least capable of managing their health.

A Commonwealth Fund study concluded that “patients who did not feel competent to manage their own health or navigate the health care system were more likely to develop a chronic disease over a three-year period than ‘activated’ patients with good self-management skills.” Further, researchers wrote, patients with low activation levels were “linked to significantly greater likelihood of hospitalization and emergency department (ED) use for ‘ambulatory care-sensitive’ conditions,” or conditions that are avoidable if properly managed.

Once a baseline PAM score is established, providers can seek to improve a patient’s ability to self-manage and then conduct a follow-up measurement to assess progress. “High-quality care should result in gains in ability to self-manage for most chronic disease patients,” ACP writes. “A positive change would mean the patient is gaining in their ability to manage their health.”

Patient engagement initiatives can be ongoing and across the board as part of a continuous care model, particularly with primary care, in which providers routinely reach out to patients with educational information and reminders about regular tests, routine visits, and medication adherence. Recurring and proactive contact with patients can help avert more serious health problems caused by delays in seeking care.

Remote monitoring and SDoH

Remote patient monitoring, whether through telehealth or wearables that capture relevant patient health data and transmit it to a shareable health record, increasingly is being deployed to provide a more holistic view of the patient. This is particularly beneficial for polychronic individuals for whom proactive outreach is critical for disease management.

Patient engagement also can help providers identify external factors impacting individual and population health. These social determinants of health (SDoH) can uncover health equity-related issues such as lack of transportation or access to nutritional foods that impact the ability of an individual to stay healthy. Providers can use SDoH to target individuals with educational efforts or referrals to social service agencies and other community-based organizations.

As provider organizations begin taking on responsibility for outcomes, the key component for them is to know exactly who in their population needs the most attention. Many VBC programs will incorporate patient outreach metrics related to either a number of anticipated visits per year or different measures of quality outcomes, such as medication compliance, something that patients can be responsible for themselves.

Patient engagement and payers

Stratifying patients by risk level and PAM score can benefit payers as well as providers. Payers can use this information to identify potential program opportunities, such as carve-outs and other “pay for quality” programs.

This enables payers to play a significant role in care coordination and management and patient engagement because payers are able to view the whole picture. Payers can see all the care team data for a patient, instead of bits and pieces. When payers share this information across the care continuum under a VBC program, the result should be better care management and a better patient experience.

Empowering the patient

Provider-payer collaboration to meet the goals of VBC cannot succeed unless the efforts truly are patient-centric. An engaged patient is an empowered patient, so it is crucial that providers and payers share with patients their personal medical histories as well as educational materials that help patients take a more proactive and effective role in their care management.

Patients shouldn’t have to struggle to obtain their health data; it should be as easy as a handful of clicks on a computer screen or mobile app. The challenge for providers and payers is that not all the data standards necessary to support robust patient engagement initiatives exist.

Given this dearth of data standards, what’s needed is a system that basically can process the data in a meaningful fashion. A longitudinal health record (LHR) that collects data from disparate sources and multiple formats is a vital component of continuous patient risk scores, risk stratification and population health management.

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