Population Health Analytics: Applying the Insights of the Care Pathways Framework
In an earlier post, (Is the High-Moderate-Low Financial Risk Model Enough to Drive Effective Population Health Management?) we introduced Care Pathways, a population risk assessment framework that stratifies individuals into 9 clinically-relevant risk stages. Unlike the high-moderate-low risk stratification method that is widely used in health management programs today, Care Pathways digs deeper into the risk categories of a population to support “less generic” interventions. We want to expand on our first post by explaining exactly how Care Pathways is used to design these intervention strategies.
The Care Pathways stages are: Well, At-risk, Pre-diagnostic, Condition onset, Early progressive, Late progressive, Critical, Sentinel event, and Recovery. Each stage represents a key point in a chronic condition trajectory and requires a unique intervention strategy. For example, a diabetic patient in the onset stage of a condition requires different health management support than a diabetic who is in the late progressive stage and likely to be hospitalized in the near future.
Each stage also queues up short and long term goals that are prioritized in a specific sequence in order to address the most important care issues and challenges the individual is facing at that point in their disease journey These goals fall into 6 different categories or domains: lifestyle behavior improvement, basic condition knowledge, understanding treatments, understanding tests, participating in medical decisions, and self-care and monitoring.
Coaching and education services for every individual take into account the stage they’re in, the sequence and prioritization of clinical goals for that stage, as well as the individual’s personal preferences and unique health and lifestyle factors.
This innovative approach to population health stratification and management is detailed in Health Dialog’s latest white paper, Delaying Disease Progression Across a Population, which covers:
- The origins of Care Pathways and how it can be used in practice
- A use case scenario that demonstrates how targeted interventions are developed
- A methodology for evaluating the outcomes of a Care Pathways-based program