White Paper 3: Intervention care before its too late
December 19, 2016
Intervention Care For The ‘Rising-Risk,' Before It's Too Late
The first white paper in this population health management (PHM) series, Chronic Disease is Healthcare’s Rising Risk, reported on the health and financial burden associated with chronic diseases, specifically the ‘rising-risk’ and ‘high-risk’ clinically stratified population groups. The second paper, A Health Behavior Change Framework for Population Health Management, set out a coordinated clinical-community structure for delivering chronic disease intervention care. This is the third white paper in this PHM series that will discuss the advantages of setting process and evaluation standards for methodology and community-digital engagement to achieve and sustain health behavior change for self-management.
Too late for what? Too late before the ‘rising-risk’ patients that have been diagnosed with one or more non-communicable chronic diseases migrating into ‘high-risk’, high cost care management.
There is a gap in care after patients have been diagnosed with one or more chronic diseases. The gap is associated with factors that, for the most part, are difficult to be effectively managed in every-day clinical healthcare delivery. This gap requires intervention care that addresses behavioral, social, environmental, and financial root causes that drive 80 percent of patient health outcomes.