Successful value-based care (VBC) programs use cohort management to impact care beyond a clinical level and address many of the underlying social needs that impact care delivery and outcomes. Social determinants of health, attributed with an estimated cost of 1.7 trillion dollars, presents both a humanitarian and cost problem that needs to be addressed. One way to address SDoH is through cohort management. Managing cohorts, networking with community-based organizations (CBOs), and leveraging the right technology will set your course for maximum impact.
Cohort management can be used to create a value-based care program by calling partners to form formal networks that better integrate services. A network comprised of both healthcare providers as well as CBOs enables collaboration between providers and community health leaders in ways that streamline services together while being able to focus on a specific population.
Networks set the inclusion criteria and partners come together and build consensus on the population they want to serve, how they will better streamline services, how they will engage patients and keep them engaged, and define core strategies and services to achieve preset goals. As a result, engagement efforts are better targeted for maximum impact.
Together, providers and CBOs as a network can manage a defined population cohort with the intent to service specific needs, including social determinants of health, and better engage these cohorts with tailored healthcare services. A network approach facilitates better integration between clinical and social providers, allowing both groups to do what they do best while also being interoperable, tracking results, and reporting.
VBP cohort management tools allow users to easily group individuals by a variety of criteria: clinical conditions, costs, mental health and substance use disorder diagnoses, social determinants of health, geography, and co-morbidities. Cohort management dashboards facilitate informed strategies to meet patients’ needs and provide efficient aggregation of individual patients’ data from multiple sources. This allows care teams to focus on individual needs in a way that is cost-effective and easily scalable.
VBP cohort management tools integrate a variety of data types and sources (including billing data, clinical data from a HIE, and needs assessment survey data), making them available for building cohorts. Priority cohorts can be defined based on parameters relevant a health plan’s needs and can then assign the population to a specific care team.
Cohort management tools provide the added benefit of providing networks a uniform interface to monitor and track network performance on a regular basis. Instead of having to reconcile data separately, they’re able to see the same information on the same screen, seeing their collective impact.
To impact care on a large scale, it’s necessary to continually look at care outside of the clinic and take steps to engage the community to better understand their needs and how to best deliver interventions that reduce gaps in care for certain population segments. Together you, your providers, and CBOs will be able to see and reap the benefits of healthier populations, higher quality care, and lower costs.