MedCity Influencers, Health Tech, Physicians

Personalizing digital care management: How dynamic care paths drive patient engagement and support better outcomes

A patient-centered digital care management platform functions as a kind of continuous feedback loop, serving as a virtual partner in the patient’s journey to better health. Here are the primary factors at work in effective digital care management design.

In 2020, three healthcare trends collided to give rise to a new era of digital care management: the rapid ascent of telemedicine, the push for patient-centered care, and the continuing shift toward value-based measurement. As providers become more dependent upon virtual care alternatives, health systems are evaluating the quality of various care management platforms. Can they help patients manage their chronic conditions, or successfully coach them through post-operative recovery?

As the disparity between patient portal availability and adoption has taught us, usability is the key to driving active patient engagement in digital tools. But for patients, what makes a digital care management platform usable has more to do with content personalization and care continuity than the simplicity of its user interface. Let’s explore the primary factors at work in effective digital care management design.

Individualized Content and Just-in-Time Delivery

Educational content presented on a care management platform should always be relevant to the patient’s health status and care journey. Ideally, a patient’s profile should include not only relevant clinical data, conditions, comorbidities, and medication, but also social determinants of health, as these factors influence how a patient is likely to respond to treatment.

To be useful, content must be delivered at the appropriate points along the patient journey, and in a manner that satisfies communication preferences, respects their technological acumen, and motivates behavioral change. Before surgery, patients need information on how to prepare themselves and their homes for upcoming procedures; after surgery, they need information on how to manage swelling, monitor symptoms, and control their pain.

Many care management platforms rely on a plethora of static content pieces rather than dynamic ones, as baseline content requires less effort and technology to establish. However, the benefits of a dynamic approach are legion. Videos and classes, particularly those with interactive user elements such as teach-back quizzes, are far more likely to spark user engagement than mere articles.

Patient-Centered Goals and Gamification

Patient goal setting is also crucial, as it empowers patients to work toward accomplishing meaningful milestones rather than arbitrary goalposts. Let’s take post-operative patients as an example. Perhaps a patient finally decided to get a hip replacement because she wanted to dance at her grandchild’s wedding. Just as patients’ reasons for surgery are often personal, so are their motivations for working through the challenges of recovery.

By customizing care path milestones and tracking their progress, patients are more apt to attend to the day-to-day work of achieving a goal. In healthcare as in life, goal achievement is one of the biggest drivers of satisfaction. In addition to supporting higher patient satisfaction rates, ongoing monitoring of patients’ progress toward their goals is one of The Joint Commission’s requirements for various Disease-Specific Care Certification programs.

When patients hit a milestone – even if the milestone is simply logging in for seven consecutive days – the system should reward them with a badge, celebratory confetti, or other recognitions to incentivize the behavior. Research shows that the use of game design elements can be very effective in driving health-related behavioral changes in targeted patient populations.

Validating the Patient-Physician Relationship

 Another key element of effective digital care management centers on the patient-physician relationship. Patients care deeply about how well their physicians listen to their concerns and explain treatment options. In fact, both patients and physicians agree that the most important determinant of quality healthcare is a strong patient-physician relationship.

A well-designed care management platform uses personalized content not only to present an optimal care path, but also to reassure patients that their physicians know who they are and understand their struggles. For example, if a patient isn’t a smoker but his pre-operative content includes information on quitting smoking before surgery, the patient might be offended. This type of disconnect between content and a patient’s real-world needs makes it easier to dismiss subsequent educational material.

For patients, active back-and-forth communication with their physicians is a fundamental component of maintaining trust. Using patient-centric language in a care management tool can underline that crucial patient-provider relationship. There is a world of difference between “complete these forms by Tuesday,” and “let your physician know how you’re doing today!” When patients feel seen and heard, they are more likely to comply with their care regimen. 

Creating an Exemplary User Experience

The initial experience on a care management platform is pivotal, as patients can easily become overwhelmed without step-by-step guidance. When they are immediately confronted with an enormous content library and no directives for how to use or prioritize that information, they are likely to disengage. Receiving meaningful, guided content on first use helps patients recognize how a digital tool can contribute to their overall care journey.

Typically, providers will give patients written directions on how to access a care management platform. If patients neglect to log in, they should receive a follow-up email or call to assist them in overcoming any technological barriers. Personalized attention at this stage of the process helps drive high patient opt-in rates.

Upon first login, patients should receive a customized welcome message and be asked a few demographic questions. Their answers should then be used to customize an intelligent care pathway. For example, if a patient walks with an assistive device, one of her first videos might be about how to safely navigate the stairs with a cane.

Real-Time Care Path Adjustments

While much care management is standardized, the ability to make small care path adjustments to reflect differences between facilities and surgeons is key to helping patients engage. When the feedback patients hear from their doctors is repeated verbatim during their digital experience, they are far more likely to view a digital tool as part and parcel of their overall care. When care pathways are incongruent with the doctor’s focus, patients are apt to see a digital platform as more of a bureaucratic task to complete (or ignore) rather than an essential recovery tool.

To drive this personalized care experience, of course, the care management tool must not only collect input from the patient, but also notify providers about how the patient is doing. Care management platforms that use AI to capture patient input points can more easily make real-time adjustments to care pathways and alert clinicians when necessary. During the patient’s visit, a nurse practitioner might be prompted by the tool to check in with the patient about mobility issues or pain management.

As anyone who’s ever had surgery can tell you, recovery is not a straight line. If a patient has multiple setbacks in a row, his patient engagement platform should be intelligent enough to register that progress has stalled—and intervene with new material to get progress back on track. Adaptive patient education uses a patient’s participation and direct input to trigger more effective care pathways. For example, a patient could be asked to score the difficulty of a particular exercise video, which would then influence the next set of exercise videos received.

Patient pain assessments are also a popular feature in digital care management tools. A care management platform can supplement standard pain-scale reporting with questions about recent levels of activity or adherence to a medication schedule. Patients might then receive guidance on how to rest following activity, or how to alternate anti-inflammatory medications for longer-lasting relief. The platform can alert care teams when patients experience unusual levels of pain without a known cause.

Further, providers should be able to update instructions or protocols on the fly, so that patients don’t receive incorrect information through their care management platforms. Patients who have carefully followed directions to abstain from drinking water the night before surgery will not be pleased to be asked if they’re hydrated when they arrive. A good digital care management tool will allow protocol changes to be automatically updated as necessary.

Collecting Patient-Reported Outcomes

For many healthcare systems, one of the main benefits of investing in a care management platform is the potential to collect patient-reported outcome measures (PROMs), as these are necessary for payer reimbursement—and can also lead to greater reimbursement under value-based care initiatives.

CMS has included PROMs and patient-reported experience measures (PREMs) as part of its Merit-based Incentive Payment System (MIPS) in the past, and recently proposed rules to discuss the electronic collection and reporting of digital quality measures (dQMs). Much work is being done to determine what digital patient-reported outcome performance measures (PRO-PMs) might look like, and PROMs collection is already beginning to be required under some plans.

However, not every PROMs collection method will yield the same results. To achieve a PROMs collection rate of 85% or higher, healthcare systems first need a high patient opt-in rate for their care management platforms. And most importantly, they need that platform to be an effective one. If patients do not believe that a care management platform has been instrumental in their wellness or recovery, they will not feel beholden to fill out forms on the provider’s behalf.

A well-designed platform will give patients the ability to complete their PROMs surveys without logging in, via a secure link delivered through email or text. It will also combat form fatigue by parceling out these requests over time. The better a provider’s care management platform, the more likely it will collect not only short-term, post-episode outcomes, but also long-term ones. When providers can collect clinically validated PROMs over a three-year timespan, they are better able to use these measures to drive performance improvement.

Not all digital care management tools are created equal. AI-enabled ones have the capacity to capture numerous patient inputs to drive an intelligent care plan that responds to each patient’s daily needs, thereby increasing engagement. A patient-centered digital care management platform functions as a kind of continuous feedback loop, serving as a virtual partner in the patient’s journey to better health.

Photo: tonefotografia, Getty Images




Bronwyn Spira is a physical therapist, CEO and entrepreneur with 20+ years of clinical and managerial experience in multiple healthcare settings. She founded Force Therapeutics to solve her own patients’ care delivery challenges and help them stay connected and in control of their care. Prior to founding Force Therapeutics, Bronwyn ran the Inpatient Rehab department at Rusk Rehabilitation Center at NYU Langone Health before founding and running a successful New York-based multi-clinic practice. She received her master’s degree in physiotherapy from the University of the Witwatersrand in South Africa.

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