Use care coordination, mHealth to better serve vulnerable populations

Coordinated care and mHealth technologies are key to reducing disparities in care for vulnerable populations, according to an article at Health Affairs. Research on improving care tends to be narrowly focused and take too long to bring change at the clinical level--if it ever does, writes Joseph West, an epidemiologist and statistician, who is senior partner at the consultancy NextLevel Advisory Group and chief population health officer for NextLevel Health, a Medicaid managed-care entity.

The patient-centered medical home (PCMH) model, along with better data capture and analysis, offers the potential to bring an array of stakeholders together to improve care based on data compiled in real time.  mHealth technologies--including smartphones, Bluetooth-enabled patient monitoring devices, tablets, and cloud-based software applications--already are being implemented in low- and middle-income countries for real-time data collection, patient monitoring, client-centered care management, and health information exchange.

These devices allow for community health workers to include factors such as transportation needs, family dynamics and more into the record to help create individualized care plans and outreach strategies for vulnerable populations, according to West. The use of health information platforms, EHRs, and non-physician personnel such as nutritionists and navigators are vital to such efforts, West writes, while dashboards and report cards can help measure progress against key benchmarks.

A study of patient-centered medical homes published in the Annals of Internal Medicine found that technology alone did not improve care, but rather a team-based culture of quality improvement.