In a 5–7 page written assessment, determine how health care technology, coordination of care, and community resources can be applied to address the patient, family, or population problem you’ve defined.
Leveraging Technology and Resources to Improve Health Outcomes
In today’s modern healthcare system, technology and care coordination play an increasingly important role in helping patients, families, and communities achieve optimal health and well-being. By utilizing available tools and connecting individuals to necessary support services, providers can help address a wide range of medical, social, and environmental issues that impact health. This paper will explore how applying health information technology, strengthening collaboration between care teams, and linking individuals to community-based resources can help solve patient, family, and population health problems.
Health Information Technology
Health information technology (HIT) encompasses various digital tools and systems that can enhance healthcare delivery and outcomes. Electronic health records (EHRs), for example, allow providers to securely store and share patient medical information, prescription histories, lab results, and more between care settings (HealthIT.gov, 2022). This facilitates care coordination and helps avoid dangerous errors, delays, or duplications that can occur when records are solely on paper. EHRs also enable clinical decision support tools that draw from best practices and give recommendations to providers in real-time, helping to ensure patients receive evidence-based care (HealthIT.gov, 2022).
Telehealth technologies have expanded access to care, especially for patients in rural areas who previously faced transportation barriers to see specialists (Bashshur et al., 2016). Virtual visits allow patients to conveniently see providers from the comfort of their own homes using video conferencing on computers or mobile devices. This is especially useful for managing chronic conditions, providing counseling or therapy services, conducting follow-up appointments, and addressing minor acute issues (Bashshur et al., 2016). Telehealth saw unprecedented growth during the COVID-19 pandemic when it became a lifeline for many to safely receive routine and urgent care without risking virus exposure (Hollander & Carr, 2020). As broadband internet access continues to expand in underserved communities, telehealth promises to play an even greater role in connecting patients to needed services.
Personal health records (PHRs) empower patients and families by giving them electronic access to their health information, including the ability to view test results, update medication lists and allergy profiles, schedule appointments, and communicate securely with their care team (HealthIT.gov, 2022). PHRs foster greater engagement in one’s own health by making medical data easily accessible outside of clinical visits. They also allow sharing access with selected family members or caregivers, improving coordination of care for the whole household or support system.
Care Coordination
Care coordination involves deliberately organizing patient care activities and sharing information among all involved providers to achieve safer and more effective care (McDonald et al., 2007). This is especially critical for patients with multiple chronic conditions seen by various specialists, as fragmented or uncoordinated care can lead to dangerous gaps, overlaps, or inconsistencies in treatment plans. Care coordination is associated with improved health outcomes, lower readmission rates, increased patient and provider satisfaction, and reduced healthcare costs (McDonald et al., 2007).
Effective care coordination relies on open communication between the full care team, including primary care physicians, specialists, nurses, social workers, pharmacists, and other allied health professionals (McDonald et al., 2007). Regularly scheduled inter-professional care team meetings, whether virtual or in-person, allow for comprehensive discussion of shared patients and development of unified treatment strategies. Care coordinators play an important role in facilitating these meetings, ensuring all necessary parties are present and that action items are assigned and followed up on.
Care plans are another essential tool for documenting agreed upon care processes and responsibilities of each provider (McDonald et al., 2007). These living documents are updated as patient needs or treatment plans change. Having a standardized care plan format accessible to all providers in a patient’s EHR streamlines coordination and prevents gaps in responsibilities from falling through the cracks.
Community Resources
While medical care addresses health from a clinical perspective, social and environmental factors have a tremendous influence on overall well-being and outcomes. Connecting individuals to community-based resources can help address some of the non-medical needs that impact health, such as access to nutritious food, safe housing, transportation, education services, and social support (Healthy People 2030, 2020).
Community health workers play an important role in identifying patients’ social needs and linking them to appropriate local programs and services (Healthy People 2030, 2020). These frontline public health professionals are uniquely qualified due to their understanding of both medical and social issues as well as familiarity with available community resources. They can Help with applications for public benefits like Medicaid/Medicare, subsidized housing, food Helpance, utility payment Helpance, and more.
Local non-profit organizations also provide invaluable services like food banks, clothing closets, homeless shelters, after school programs, senior centers, support groups, and more (Healthy People 2030, 2020). Maintaining an up-to-date community resource directory that is easily accessible to both patients and providers is crucial. This allows needs to be addressed promptly instead of falling through the cracks. Telehealth and patient portals provide convenient platforms for sharing these directories digitally.
Case Study: Addressing Social Determinants of Health in Seniors
As a case study, consider an elderly patient with multiple chronic conditions who lives alone in subsidized senior housing. During a routine primary care visit, the physician identifies through screening questions that the patient has been struggling with medication adherence due to difficulty affording prescription copays. They also note the patient has been missing some specialty appointments due to lack of reliable transportation options.
To address these social barriers impacting health, the care team would take the following coordinated steps:
The care coordinator would connect the patient to the facility’s community health worker to apply for prescription copay Helpance programs and Medicaid if eligible (Healthy People 2030, 2020).
The community health worker would also link the patient to the local Area Agency on Aging to inquire about subsidized transportation vouchers for medical appointments (Healthy People 2030, 2020).
The primary care office would arrange for a telehealth follow up with the cardiologist to avoid any further missed visits while transportation is addressed (Bashshur et al., 2016).
The care plan would be updated in the EHR to document resolution of these social needs and ensure all providers are aware of the coordinated solutions (McDonald et al., 2007).
At the next interprofessional team meeting, the patient’s progress and any ongoing needs would be discussed to maintain holistic care (McDonald et al., 2007).
Through this multidisciplinary approach leveraging technology, care coordination, and community linkages, barriers impacting the patient’s health have been addressed and the risk of negative outcomes is reduced.
Conclusion
In summary, utilizing health information technology, strengthening care coordination between providers, and connecting individuals to community-based resources are powerful strategies for solving complex patient, family, and population health challenges. A team-based approach is necessary to comprehensively address both medical and social determinants of health. Continued advancements in digital tools, care models, and available community services will further empower providers to deliver whole-person, patient-centered care and optimize outcomes.
References
Bashshur, R. L., Shannon, G. W., Smith, B. R., Alverson, D. C., Antoniotti, N., Barsan, W. G., … & Gonzales, R. (2016). The empirical foundations of telemedicine interventions for chronic disease management. Telemedicine and e-Health, 22(9), 761-800.
HealthIT.gov. (2022). What is health IT? https://www.healthit.gov/faq/what-health-it
Healthy People 2030. (2020). Social determinants of health. https://health.gov/healthypeople/objectives-and-data/social-determinants-health
Hollander, J. E., & Carr, B. G. (2020). Virtually perfect? Telemedicine for Covid-19. New England Journal of Medicine, 382(18), 1679-1681.
McDonald, K. M., Sundaram, V., Bravata, D. M., Lewis, R., Lin, N., Kraft, S. A., … & Owens, D. K. (2007). Closing the quality gap: A critical analysis of quality improvement strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US).
