Tracking Patients: Getting the Right Data (and Tools) to Enhance Care

In behavioral health and human services (BHHS), technology has evolved rapidly to provide more personalized and outcome-focused care. Central to this progression is the meticulous tracking and measurement of patient data. Tracking patients is pivotal to better health outcomes and capturing a comprehensive view of a patient — from demographics to treatment planning — to elevate the quality of care. 

Here, we’ll explain more about why a patient tracking system is so important. We’ll also show how healthcare providers can harness the power of electronic health record (EHR) systems and patient engagement platforms to better understand, intervene, and innovate for a stronger continuum of care.

Tracking Patients: Why We Track What We Track

In healthcare, there's a popular saying, "What gets measured, gets improved." This statement is undoubtedly true. However, monitoring everything can be worse than monitoring nothing. Patient data is crucial for various aspects of patient care and organizational efficiency. 

For one, making data-driven decisions is vital for enhancing patient care and is arguably the most critical reason for doing so. Documenting outcomes, monitoring changing demographics, and measuring quality of care are equally important as they provide essential insights. Below are specific patient tracking examples, implications, and tools.

Patient Health Outcomes and Treatment Plans

Patient satisfaction surveys and reports offer insights from the patient's perspective that objective metrics alone may not capture. BHHS clinicians are pros at translating patient-derived information into objective data for diagnosis, treatment, and monitoring.

Example: An individual with depression reporting improved mood and increased motivation post-intervention; a child in foster care feeling more secure and developing trust with caregivers. 

Implication: This provides direct evidence of patient safety and the efficacy of therapeutic or service interventions from the patient's or service recipient's perspective.

Technology: Comprehensive EHR software centralizes medical records and treatment histories, interventions, medications, and outcomes, enabling providers to quickly gauge current treatment and inform therapeutic strategies. 

Patient engagement tools help capture and record assessments such as patient-reported outcome measures, personal health observations, and patient feedback. 

Together, they offer a simple way to track both clinical and experiential aspects of care. By leveraging these platforms, providers can systematically monitor patients, and assess and adjust treatment plans to ensure they align with the dynamic nature of patient health and well-being.

Assessments used to measure patient and health outcomes include:

• Brief Addiction Monitor (BAM): A holistic assessment tool, BAM covers diverse areas, from physical health and mood to social support and recovery objectives
• Short Inventory of Problems Revised (SIP-R): A tool that focuses on 17 key items, SIP-R evaluates a patient's physical, social, intrapersonal, interpersonal, and impulse control challenges
• Treatment Effectiveness Assessment (TEA): A tool that allows users to evaluate their substance use, health, lifestyle, and community on a scale of 1-10
• Patient-reported outcome measures (PROMs): Feedback tools that capture the patient's self-assessment of their health and well-being; they provide direct insights into how patients perceive the effect of illnesses and treatments on their lives

Patient Demographics and Social Determinants of Health

Demographics are more than just a series of checkmarks on a form, numbers on a spreadsheet, insurance information, or identification methods; they are the foundation of individualized medicine and health equity. 

Example: Age, gender, patient location, family member, and socioeconomic status

Implications: By monitoring demographic changes, we ensure that healthcare providers have a holistic view of the patient. Accurate demographics are also vital for administrative purposes, such as billing, communication, and follow-up. Any inaccuracies can lead to administrative mixups, miscommunication, or medical errors, especially if patients are misidentified.

For example, age influences metabolism and the body's response to medication, gender affects the presentation of symptoms, and socioeconomics may impact the efficacy of treatments. Similarly, understanding a patient's background can provide insights into their access to resources, social support systems, and potential environmental stressors, all of which may influence their health and response to treatment.

Technology: Coordinated EHR software and patient engagement solutions are indispensable for capturing and maintaining accurate patient demographic data. EHRs streamline the workflow of demographic tracking by providing a structured repository for recording vital demographic details such as age, gender, ethnicity, and socioeconomic status, ensuring that healthcare providers have ready access to this information during every patient interaction. Patient portals allow patients to update information as it changes, which helps patients actively participate in maintaining the accuracy of their profiles.

Patient engagement tools can help you track patient demographics, receive real-time updates, and message securely with your patients. This collaborative approach streamlines the process of tracking demographic data and leads to more informed and personalized healthcare.

Quality Measures

Certified Community Behavioral Health Clinics (CCBHCs) stand at the forefront of delivering comprehensive, high-quality mental and behavioral health care. Central to this commitment is their adherence to a stringent set of quality measures, which help ensure that every patient receives effective and evidence-based care.

Example: Follow-up after hospitalization for mental illness. This measure looks at the proportion of patients who receive timely follow-up care post-hospitalization for a mental health condition.

Implications: There are several.

• Clinical implication: Effective follow-up can reduce the risk of relapse or readmission, ensuring the continuity of care. A lapse in this measure might indicate gaps in the care continuum and require more structured discharge planning and coordination for better outpatient success.
• Patient implication: Regular follow-ups can make patients feel valued and cared for, enhancing their trust in the healthcare system. This can also encourage adherence to post-discharge care plans.
• Operational implication: A high success rate in this measure could position a clinic as a leader in patient care while failures might highlight logistical challenges, such as wait time, missed phone calls, scheduling, or check-in and patient flow bottlenecks.

Technology: EHRs by design are great tracking tools as they centralize a vast array of patient data, from medical histories to treatment outcomes. 

Patient engagement platforms are another excellent tracking solution because they play an instrumental role by capturing real-time patient feedback and self-reported outcomes and facilitating direct patient-provider communication. This synergy ensures that clinical data and patient-centric insights are holistically integrated, enabling healthcare providers to monitor and assess performance against quality benchmarks. 

Through user-friendly dashboards, alerts, and data visualization tools, these platforms streamline the process of measuring, understanding, and improving care quality. As a result, healthcare delivery consistently aligns with established standards and patient expectations.

Quality measures tracking encompasses a diverse range of areas in behavioral health care, emphasizing both clinical and patient experience facets. 

CCBHCs track the following quality measures:

• Time to Services (I-SERV): This measures the time taken from initial contact to the first offered appointment, ensuring timely access to care
• Depression Remission at Six Months (DEP-REM-6): Tracks the rate of patients who show remission or significant improvement in depression symptoms six months after initial diagnosis
• Preventive Care Screening for Unhealthy Alcohol Use: Ensures patients are screened for unhealthy alcohol use and, if identified, receive counseling
• Screening for Depression and Follow-Up Plan: Screens for depression and ensures those screening positive have a documented follow-up plan
• Screening for Social Drivers of Health (SDOH): Recognizes socioeconomic and environmental factors in ensuring patients are screened for these determinants
• Preventive Care & Screening: Tobacco Use: Prioritizes the screening of tobacco use and offering cessation interventions when needed
• Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment: Ensures young patients diagnosed with MDD receive a thorough suicide risk assessment
• Adult Major Depressive Disorder: Suicide Risk Assessment: Ensures adults diagnosed with MDD undergo a comprehensive suicide risk assessment
• Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents: Promotes holistic health by ensuring weight assessment and offering appropriate counseling
• Controlling High Blood Pressure (CBP-AD): Tracks the management and control of hypertension in adult patients
• Patient Experience of Care Survey: Aims to gather feedback directly from patients about their overall experience of care received
• Youth/Family Experience of Care Survey: Captures feedback from youth and their families, focusing on their unique experiences and needs
• Adherence to Antipsychotic Medications for Individuals with Schizophrenia: Ensures people diagnosed with schizophrenia continue taking antipsychotic medications
• Follow-Up After Hospitalization for Mental Illness: Monitors the post-hospitalization care for adults and children, ensuring they receive appropriate follow-up services
• Initiation and Engagement of Substance Use Disorder Treatment: Tracks how many patients enter substance care after diagnosis
• Follow-Up After Emergency Department Visit: Ensures patients visiting the emergency department for either mental illness or substance use receive timely and appropriate follow-up care
• Plan All-Cause Readmissions Rate (PCR-AD): Measures the rate at which patients are readmitted to any facility for any reason after a discharge, which can indicate care quality and effectiveness of treatment
• Follow-Up Care for Children Prescribed Attention-Deficit Hyperactivity Disorder (ADHD) Medication (ADD-CH): Ensures that children prescribed ADHD medication receive appropriate follow-up care to monitor efficacy and side effects
• Antidepressant Medication Management (AMM-AD): Assesses how effectively antidepressant medications are managed for adult patients to establish consistent and beneficial usage
• Use of Pharmacotherapy for Opioid Use Disorder (OUD-AD): Tracks the rate at which patients diagnosed with opioid use disorder are provided with and use pharmacotherapy
• Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH): Ensures that young patients on antipsychotics get first-line psychosocial care as part of a comprehensive treatment approach
• Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH): Tracks the rate children and adolescents on antipsychotic medications receive metabolic screenings, given the potential metabolic side effects associated with these drugs

Benefits of a Technology-Driven Approach to Patient Tracking

Technology improves patient data collection, tracking, and reporting. Before digital advancements, patient information was often collected manually. As a result, sometimes that information was incoherent, fragmented, and unusable. The lack of integration made it nearly impossible to share information with other providers and effectively track patient progress over time.

But that’s no longer the case. Tracking patients can be much easier (and more effective) thanks to software solutions like ContinuumCloud. By seamlessly integrating robust EHR functions with interactive patient engagement tools, ContinuumCloud gives healthcare providers a 360-degree view of each patient. 

The platform simplifies the process of capturing, analyzing, and leveraging data so you can adhere to quality measures and optimize treatment protocols. ContinuumCloud champions a patient-centric approach, fostering better communication, enhancing patient trust, and ultimately driving superior health outcomes. And it’s HIPAA-compliant, which means all communication and health information is protected.

Streamline Tracking Patients With Simple-to-Use Technology

Patient data isn't just pivotal at the point of care; it's also crucial for healthcare organizations aiming to improve population health and reduce disparities in outcomes among different demographic groups. With accurate demographic data, you can uncover trends in health outcomes and devise strategies to address the needs of diverse populations more effectively.

Patient tracking offers numerous benefits to healthcare providers and patients, especially in the mental and behavioral health fields. This process involves continually observing patients' symptoms, behaviors, and progress. By meticulously recording and analyzing this data, you can unearth vital insights about the care you provide and your patients' mental health conditions to fine-tune treatment strategies for optimal outcomes. 

Going digital doesn’t have to be difficult. Connect with us today to learn how to simplify the transition process.