Why Population Health is the Future of Home Care

Technology in home health care offers many opportunities to reduce costs, streamline care efficiencies and improve overall patient outcomes. Not only are new technologies making it easier than ever for home health care agencies to track more data, they are also enabling population health.

With numerous new payments models coming down the pike, like value based purchasing, home health agencies have an opportunity to become more involved in population health with the support of new technologies. While the fee-for-service model doesn’t necessarily support population health aims, the home health industry can become much more involved in care coordination as new incentives push integration across care settings.

“It’s an exciting time for population health,” Michael Dulin, director of the Academy for Population Health Innovation at the University of North Carolina Charlotte, said during HIMSS Pop Health Forum 2016 in Chicago. “We have the data, we have the technology, and the current system is broken.”


To achieve population health goals, there are five steps a health care provider can take:

1. Strategy

The first step any home health agency should do is to take stock of current processes, according to Dulin.


“Take inventory,” he said. “You have to know what you’re doing now.”

From there, you can formulate a strategy by identifying where the business is meeting its goals and compare against other benchmarks. Part of strategizing also involved setting new goals with population health aims, such as improving care coordination and clinical outcomes. Within this step, businesses also need to look a the scope of the work and determine what tools and resources can help achieve these outcomes.

2. Data

After focusing on a strategy, leveraging technology can help businesses gather the data they need to become preferred partners and an instrumental arm in population health successes. Data can help a home health company understand their risks, particularly patient risks, and define populations of patients.

However, collecting data is not enough on its own. More data should help predict outcomes of certain patients and enhance care pathways that can help mitigate risks.

3. Engagement

Engaging key stakeholders in new processes and IT systems is essential. Patients, providers and partners all need to be engaged with the same goals in mind, and will allow businesses to pilot new approaches.

Engaging patients in the process can help agencies understand what is working and which areas need improvement. Data can provide a qualitative assessment to enable outcome improvements.

4. Implementation

When implementing and disseminating new business strategies with clinical aims, care coordination is essential, and so is determining the point of care decision support. For home health care companies, this can mean helping patients navigate the health care system and overcome some of the social determinants of health.

Linking to other community resources and partners is another crucial element of this, according to Dulin. While Dulin maintains that many of the responsiblities of solving the social determinants of health fall within the public health domain, population health providers can help facilitate patients around those challenges, particularly home health care and community-based services providers.

5. Reflection

Once new initiatives have been put in place, taking a qualitative and quantitative assessment is the key to moving forward, Dulin said. Technology can support thee evaluations, but creating meaningful population health successes includes analyzing those evaluations for improvements.

Written by Amy Baxter

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