Population Health Management eBook

Population Health Management

Automated Interventions Are Essential

The last chapter described the importance of prompt patient interventions based on insight from a population health management (PHM) technology platform. Conducting targeted interventions, although guided by up-to-date and reliable analysis from the technology, can still be time consuming.

That is why PHM care managers need to be supported in their role beyond automated trend dashboards and reports. Automated patient communication and patient-reported data capture can be one of those additional tools. Handling simple outreach and patient-generated data capture helps reduce the overall burden on care managers and can make PHM much more feasible and effective, even for organizations that are just launching into this new model of care management.

Automated Interventions For Outreach And Patient-reported Data Capture

Interventions for patients outside of a healthcare facility are typically conducted through manual phone calls or sending postal mail, which are time consuming, but also frustrating for providers due to slow or low response rates. Mailing paper surveys to gather patient-reported data, either about their care experience or their conditions, are burdensome, too.

Automated interventions delivered through an advanced PHM technology platform can significantly reduce a care manager's workload and improve both patient response rates and their experience.

Automated interventions delivered through an advanced PHM technology platform can significantly reduce a care manager's workload and improve both patient response rates and their experience. By analyzing comprehensive, aggregated data sets from across the care continuum, the technology identifies negative health trends and launches the intervention. Higher response-rate automated interventions may include notifications or surveys sent to a patient's mobile device, or an interactive voice response phone call to interview a patient about their health status.

Automating the intervention not only saves time for providers but also aids in response to patient health trends as quickly as the data analytics technology identifies a negative trend. Timely, prevention-focused interventions help patients stay engaged in their care, avoid an emergency department visit or hospitalization, and prove providers care about their health year-round, not just when they have an appointment. Large populations of patients also increasingly prefer learning about their health and communicating with providers through secure patient portal messages, smartphones and short message service (SMS) or texting applications. In fact, one study showed that patients who received text message reminders and voicemail messages had a 15 percent higher appointment attendance rate compared to patients who received voicemail messages alone. Advanced PHM platforms can automate this electronic communication that nurtures stronger engagement and care-plan adherence.

How To Automate Interventions

Based on discrete events in a patient's life, a targeted and automated communication can be sent to a patient when needed.

A small sample of those events may include:


A recent hospitalization and discharge


High volume of emergency department visits


Referral visit


Skipped appointments


Unfilled prescriptions

As stated above, organizations can reach out to these patients using numerous automated methods such as text messages, an interactive voice response phone call, a secure portal message, or even a letter sent through the postal mail for patients who aren't as comfortable with technology. Such communication preferences are tailored to the patient or the population within the PHM technology platform.

Likewise, creating these outreach campaigns can be just as flexible using a rules-based engine that is easily configurable based on any number of patient variables, including specific chronic condition(s), age, sex, health plan, smoking status and recent hospitalization. The next chapter explores in greater detail how to configure a targeted and effective automated outreach campaign based on your organization's quality and cost goals.

Surveys For Patient Reported Data

An increasingly popular automated outreach method that helps an organization capture valuable patient-reported data, but also nurtures engagement, are surveys delivered to patients' mobile device or portal. Questions can inquire about any aspect of the patient's chronic condition management, post-discharge recovery or care delivery experience. Based on patients' responses, especially if answers indicate they are struggling with self-management, the intervention can be escalated to a live care manager for a more in-depth interview.

Surveys are especially useful when patients visit specialists or other healthcare facilities that are unaffiliated with your healthcare organization. In these instances, an organization may not discover the out-of-network patient care was delivered until after the patient's health-plan has reimbursed the claim, which could be 90 days later. Effective PHM relies on up-to-date data so interventions are timely and effective. Capturing data from patients through automated surveys helps eliminate that lag time.

Enabling Stronger Patient Engagement

Automated communication and intervention enables stronger patient engagement even if patients are not interacting with a live care manager because it demonstrates the healthcare organization is vested in the patient's health and quality of life year-round. While it is a valuable management support tool and can help patients stay adherent to their care plans, it is not a replacement for clinician experience and judgment. Automation simply eliminates some of the time-consuming, non-essential activity so care managers can focus their clinical and interpersonal skills on helping more complex and challenging patients achieve optimal outcomes.

Apart from detailing how to build a campaign, the next chapter also describes how to measure its success and stay on the upward trajectory.
InteliChart Chapter 4

How insights from PHM can lead to prompt patient interventions.

Chapter 6 InteliChart

Setting up successful outreach campaigns to meet your goals.