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While the health care continuum remains more or less the same, our perspective across that continuum has changed significantly, thanks in large part to the lens healthcare analytics provides. Historically, healthcare analytics has primarily been used to manage acute, inpatient episodes of care within the four walls of the hospital. With the onset of accountable care and payment reform, organizations are now asking that cross-continuum analytics expose greater opportunities for streamlined, optimized care. Shifting our ingrained cultural habits and competencies from episodic management to the more holistic, health care continuum-oriented population management can be a daunting enterprise.

With 15.5 million individuals covered under high deductible health plans1, many patients are delaying care as long as possible. Meanwhile, hospitals are seeking ways to reduce costs in order to survive reduced reimbursement. Organizations are now turning their attention toward new ways to manage health care costs outside of traditional venues.

In fact, CMS is acutely aware of the community challenges embodied by the mandate to reduce overall costs for an aging, more complex patient population. Opportunities for cost reduction are legion, with an average of 20 health care providers involved in the care of just one patient2. Patients also face significant geographic discrepancies in the cost and application of resources. For example, a patient in Connecticut is twice as likely to end up in a nursing home as an Arizona resident3. Spending in Louisiana is roughly $8,800 per patient receiving home health care, $5,000 more than a patient in New Jersey4. Twenty five percent of patients in Chicago receive additional resources after leaving the hospital, three-fold the rate in Phoenix5.

Even in the same city, the same patient can incur dramatically different costs depending on the setting for post-acute follow-up care. CMS observed that a patient who suffers a stroke and is treated in a hospital with three months of subsequent care can average $40,000 if he or she is discharged to an inpatient rehabilitation facility, $33,000 if discharged to a nursing home and $13,000 if discharged to home with health aides6. Given these variations, patient-centered cost analysis that spans across the health care continuum of providers and settings becomes increasingly important.

So how can health care institutions provide the best care for their community while simultaneously managing costs? The following three key strategies will help advance cross-continuum success:

  1. Think big, but act small. Seek solutions that can facilitate the data mining and discovery process across multiple, disparate IT systems. Most organizations have multiple EHRs, along with multiple financial systems and clinical order and results systems. Instead of holding out for one solution that will illuminate every choice across your health care continuum, begin with small, iterative, and informative analysis. Remember that analytics is a journey and not a destination—and so is true reform.
  2. Identify your populations and stratify risk. These first steps are the foundation of cross-continuum analytics. Reviewing historical patterns to identify which patients are best served in specific care settings can inform best practice. Utilizing care coaches, navigators and other tiered professionals can help you ensure that patients are receiving the right care at the right time and place. These experts will also help you keep clinical professionals practicing at the top of their license.
  3. Plan with the end in mind. It is often said that discharge planning begins in the emergency room. Engaging physicians, case managers, outpatient stakeholders and – most importantly – patients and family members can help you set expectations while delivering care that supports ongoing patient health.

In an ironic twist, improved health care and greater longevity have created some unique challenges. However, as with any great endeavor, there is no reason to believe we cannot overcome the intricacies of care across the health care continuum once we unite around a single purpose.

Are you ready to turn your health care data into actionable knowledge? Learn how Healthcare Analytics solutions can help your organization analyze care across the health care continuum.

1"January 2013 Census Shows 15.5 Million People Covered by Health Savings Account/High-Deductible Health Plans (HSA/HDHPs)." AHIP. America's Health Insurance Plans, Center for Policy and Research, June 2013. Accessed December 15, 2014.
2Deutschendorf, Amy L. "Care Coordination and Linkage." Engineering a Learning Healthcare System: A Look at the Future: Workshop Summary. Institute of Medicine (US) and National Academy of Engineering (US) Roundtable on Value & Science-Driven Health Care. Washington, D. C.: National Academies Press (US), 2011. National Center for Biotechnology Information (NCBI), U.S. National Library of Medicine. Accessed December 15, 2014.
3Rau, Jordan. "Medicare Seeks To Curb Spending On Post-Hospital Care." Kaiser Health News, in collaboration with The Washington Post. Kaiser Family Foundation, 1 December 2014. Accessed December 15, 2014.

Michael Udwin

About the author

Michael R. Udwin, MD, FACOG is Executive Director of Physician Engagement Services and a member of the Web2pro Business Advisor Consultants team. With over twenty years experience as a results oriented physician leader, he leverages both health care analytics and IT resources to achieve enterprise-wide performance improvement goals. Specializing in physician alignment, Dr. Udwin recognizes the unique role providers play in the sustained consistent delivery of best practice on behalf of hospitals, health systems and communities. In addition, Dr. Udwin serves as assistant professor providing maternity care in a large academic center.


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