Combining human capital and digital health tools for better patient care

 A strategy that combines health IT and care management teams for risk reduction through effective population management in health care

As a healthcare provider, you likely have some way of identifying your high-risk and rising-risk patients. The source for such data might be a health plan that has used claims data with complex algorithms to find patients who are statistically prone to adverse health outcomes, or even simple reports from your internal staff that flag patients at elevated risk for their respective disease states (COPD, heart failure, etc.).

Once you have the list of at-risk patients, what’s next? What are you going to do to support the patients you have identified? To date, there have been two primary schools of thought: 1.) Hire care managers to facilitate care for the patient while they are outside of their brick and mortar facilities and 2.) Pick one of the growing array of patient engagement tools and cross your fingers that the technology is well-designed and clinically effective, with the risks of increased staff workload and low return on investment.

Let’s dig into the challenges and best practices for each strategy:


Care Management

Care managers can have an extraordinary impact when talking with an at-risk patient. Operating at the tops of their licenses, nurses and MAs can titrate medication, offer personalized instruction, and provide other forms of timely remote care. This high touch care helps to drive better outcomes, smaller readmission rates, and greater staff efficiency. The problem then becomes clear: how do care managers know which patients should they call today? Without technology, the solution may be to require care teams to periodically call their lists and hope the patient will answer, engage, provide an accurate update on their signs/symptoms every time. There must be a better way to put medical professionals’ hours to use.


Patient Engagement Tools

There are plenty of companies trying to improve general patient engagement. Many companies rely on broad educational to patients. While these tools may engage patients for the first week, there is significant patient drop off; for instance, only two percent of patients download the apps that hospitals recommendˆ. For technology to be worth its salt, it must keep patients of all backgrounds happy and engaged for months. while simultaneously collecting the sufficient data for well-informed care. After all, once you’ve identified your most expensive patients, the real trick is knowing that something is about to go wrong, then taking action to help each patient with his or her own unique situaiton. Technology may help automate the data collection, but even the best patient-reported outcomes trackers can’t replace humans.


Best of Both Worlds: People + Technology

Your care management team must use technology and best practices to create a feedback loop of triaged patient data that will direct their efforts to maximize efficiency and impact. Patients’ own data are only as valuable as patients engage, which means that your team needs a tool that will consistently engage patients over the entire tenure they are overseen by care management. The right combination, however, can be incredibly powerful, improving dialysis patients’ appointment adherence by 75% and reducing hospitalizations by over 50%.

Even the most talented care managers will eventually run out of bandwidth, and many digital tools are all show, no value. Furthermore, the best technologies help medical professionals do what they’re most passionate about: care for patients and positively impact people’s lives.


  1. Care managers are often missing real-time and longitudinal data for actionable insights.
  2. Patient engagement technologies must be tested in clinical settings to prove long-term effectiveness, engagement, and success catching adverse events.
  3. Tools like Epharmix are proven through randomized, controlled trials to provide the necessary feedback loop for care managers to efficiently and sustainably monitor their at-risk patients while keeping even the toughest patient populations engaged and pleased with the quality of care they’re receiving.

Interested in seeing how Epharmix uses clinical research to create patient engagement tools proven to reduce hospitalizations for patients and save time for care managers? Learn more.

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