Creating Communities of Health

by Matt Ferrari
Co-founder and Former CTO

As someone who spends every day building out the future of healthcare in the cloud, I’m optimistic about the promising improvements in population health, with increasing numbers of collaborative community care models succeeding across the country. In the past, pop health was difficult to scale across communities because it was tough to share data across the silos present in various divisions and agencies and still maintain the necessary security and compliance needed. Our industry’s work in the public cloud is changing all of that and providing for collaboration in ways never before possible. The outcome can be better patient care, reduced costs, and stronger, healthier communities.

I was recently at my 5th national HIMSS conference, and had the chance to connect with Jamie Philyaw, VP of Care Management at Community Care of North Carolina (CCNC) and Sue Powers, SVP of Sales at Virtual Health. We recorded a podcast in my CTO Talk series, (airing April 24 – May 21 at 3 pm. ET on HealthcareRadio NOW, then available on demand here on my SoundCloud playlist.)

Jamie and Sue are partnering to explore and expand on ways to address the unique needs of large, complex care-populations in North Carolina. As the nation’s longest-running home care system, CCNC works across all 100 counties in NC. They are using data to identify and provide care for patients who are seeing multiple doctors and taking multiple medications. Using Virtual Health’s Population Health Management model (PHM), CCNC is building a successful model of community partners in multi-disciplinary teams, providing patient care under a common care plan. This is pretty exciting because it can help keep people out of hospital emergency rooms and enables care givers to get in front of problems before they become emergencies. CCNC says their work saved $345 million last year and helped patients across the state break through barriers around housing, nutrition and transportation on their way to better heath.

We covered some important topics in this half-hour conversation, and I want to touch on a couple of those for you to be thinking about in your work.

Buy vs Build

I deal with buy vs. build conversations every day. The truth is, implementations are hard. Healthcare is hard. I used to be a software developer writing code. But with advances in the cloud for scaling, security and agility, people have to stop and ask if their work is really making the best use of their resources and people, or if they are allowing themselves to be bogged down in maintaining a legacy platform. Jamie talks about how CCNC was on a legacy system they built in-house. They reached a point in their evolution where they had to honestly ask if it was a smart use of their resources to continue to invest time and money in maintaining it. She says they realized as they were growing and taking on new business, and moving into an era of Medicaid reform, that they wanted to be able to take advantages of advances in cloud-based technology to build efficiencies, scale, improve patient care and increase collaboration opportunities. I’m impressed with the rigorous and thoughtful process she went through in her migration process.

Increasing Interoperability

We also talked about interoperability – a huge concern for everyone as healthcare moves from volume-based to value-based care. The bottom line is, to improve pop health and community care models you have to be able to bust silos and share data in a way that is safe, secure and allows folks to collaborate. Sue and Jamie talk a bit about how their model is stitching together a community of care givers under a common, user-friendly platform that will bring community-based providers together with patients, even in rural areas where so many patients are historically underserved.

Consideration of Social Determinants

And we talked about one off the biggest stumbling blocks in serving high need, vulnerable populations – understanding and addressing the social determinants that are in play. A lot of the patients Jamie’s group is working with are facing social barriers that are as important to address as their particular diabetes or asthma diagnosis, for example. With a clear line of sight into a common care plan and better collaboration, CCNC and Virtual Health are working to address care across the entire healthcare continuum, for better ‘whole person’ care. That may mean teaming your care group with Meals on Wheels, or transport services, as Jamie’s group has, or it may be providing therapists, coaches and counselors.

Predictive Analytics and the Role of Data

Both of my guests shared some meaningful insights on the role of data, including predictive analytics, to inform clinical risk profiles so payers, providers and care givers can better understand which patients are most likely to respond positively to certain care plans. Sue makes a great point I’d like to echo here. Having data isn’t enough. We have to take action. To transform healthcare, we have to measurably increase access to data, then we have to take informed action based on the insights we can glean from the data, driving more timely, and more effective interventions to those in need.

I invite you to give this episode of CTO Talk a listen and think about ways your community can connect the dots and break down the walls between the different people and organizations that comprise the care team. In the end, everybody can benefit.

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