Pivoting from a System centric to a community driven mindset for continuous care

Howdy! Covid 19 has shown the importance of moving from a system centric approach to a community centric mindset. Today we are focusing on how do we pivot from a system centric to a community driven mindset that will put patient centricity at the core of the system. Before we start let’s build some context.

Over the years, healthcare organizations have taken a system centric approach, where healthcare providers have provided a volume based systematic approach to care, which also revolved around fee for service. However, due to Covid, the patient surge and volume, the volume based systematic approach to care failed.

As we look into the future, we can foresee benefits in adopting a community driven continuous care model which revolves around patient first strategy. In this model of care, a patient can be supported by simply engaging a community which may involve your next-door neighbor, your local pharmacist, your relatives in the family and a purpose driven tele health network which can plug medical professionals on the fly for a value-based care delivery.

While the physician and the emergency services can be looped in quickly with a distress alarm, your neighbor next door can immediately attend or support you with a simple protocol to follow.

Below diagrams explains the concept -

In order to make this journey smooth, we need to consider building a support ecosystem that is accessible and can be consumed rapidly.

Components of this Continuous care model -

Patient at the center of the ecosystem

As patient takes the center of the ecosystem, here are the 8 dimensions of patient-centric care that became key drivers worldwide to measure service quality -

·       Respect for patient's values, preferences and expressed needs

·       Coordination and integration of care

·       Information, communication and education

·       Physical comfort

·       Emotional support

·       Involvement of family and friends

·       Transition and continuity

·       Access to care

Patient Data Exchange

With a consent from the patient, patient information should be shared across the ecosystem as the need be. With industry aiming for more standardization, healthcare applications and platform companies will support exchange of the healthcare data in unified and secured way like FHIR.

Virtual Care is one of the most essential component

As virtual care taking center stage, community care approaches will be dependent on the integrated care models where virtual care and home care approaches will address the needs of the community driven care.

Community participation needs training

In order to have 100% results with the community participation, more awareness and enrollments will be needed to facilitate a community care approach. This means the responsibilities will be shared and needs to be communicated. Right from conducting workshops to enrolling the care givers and supporters, a lot of community driven care programs will evolve their business models. While the communities start engaging, lot of data and insights will be shared back to research communities that will foster the need of evidence-

based training programs.

Incentive Programs for the community health workers

Incentive programs plays a vital role in motivating the community health frontline workers. As the healthcare worker bridges the hospital care with home care, incentive programs driven by value will help navigate faster through the system.

Community Based Health Insurance (CBHI)

Community based health insurance (CBHI) programs will also evolve with more preventive care plans along with home care and tele health reimbursement to incentivize the patient needing care. Traditionally, Community-based health insurance (CBHI) schemes have usually remained voluntary and were driven by community members pooling funds to offset the cost of healthcare. This will potentially get transitioned to a greater hospital and community care partnerships with a simple goal to improve quality of life for patients.

Focus on Measuring outcomes and Value driven from continuous care approach

It is observed that continuous care models will lead to increase adherence with the treatments in patients. Whether it is a cardiac rehabilitation program or any other support for mental health or lifestyle changes, community care has always led to higher adherences to patient treatments.

Use of Data & AI to predict interventions and outcomes

Data & AI is playing a crucial role in predicting the required interventions and recommending dos and don’t for a given situation. Right from predicting diagnosis required for a given situation to predicting accurate care outcomes, care delivery can be made more efficient. Such use of technology in continuous care model will not only improve confidence of patient, it will ease day to day life of physicians and will reduce physician burnouts. Moreover, such data from the community care platforms can be exchanged with research community to bring faster research outcomes.

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If you have a similar story or you are working on community driven continuous care model, please feel free to share your story with us. You can reach us at healthviva@taliun.com


Team HealthViva