Published November 23, 2015

What Is Population Health, Anyway? – Part V: A 10-Part Plan of Attack for Population Health

A Five-Part Series
Part V: A 10-Part Plan of Attack for Population Health

In our earlier blog entry, we posited that the term “population health” is rather meaningless unless stated in terms of how it is implemented, which involves the application of the clinical, organizational, and technical aspects of population health management.  We previously examined the clinical aspect, the organizational aspect, and the technical aspect.       

Having identified the three aspects of population health, thought leaders within the Organizational Hub can then define the concept of population health for their own population through the strategies and tactics they develop to improve the status of health for that population.  The question then becomes: what constitutes a viable, common-sense population health management program?

Let’s revisit the notion that population health management is key to thriving and surviving in the new world of healthcare payment and delivery.  Value will be rewarded over volume, and new methods will need to be adopted to promote wellness for the population served.  Value will be determined using increasingly more precise metrics gauging patient satisfaction and outcomes.  Strategies will be aimed at the entire population served while individual needs within that population will continue to be addressed.

Let’s also accept the fact that the hospital and its medical staff must be the initiators of action. They must be harnessed together, developing administrative and clinical capabilities concurrently to manage population health.  They must bring together other community services and resources that impact the social determinants of health and serve as the Organizational Hub for community action.

Given that starting point, the Organizational Hub should consider the following plan of attack:

1.       Create the trust environment within which hospital administrative leaders and physician leaders can begin to develop a common understanding of the urgency of preparing the organization to move from volume to value, recognizing the compelling need to design processes that produce value, and immediately undertake the task of reforming their mutual business and clinical operations to succeed in a rapidly changing healthcare environment.

2.       Identify the population served: i.e., identify the community which comprises the population to be addressed by a planning process.

3.       Conduct a comprehensive Community Health Needs Assessment (CHNA) which engages every entity in the community that has an impact on the social determinants of health for the residents of the community.  Engage those constituent organizations in an honest evaluation of the community’s population health status and a detailed planning process designed to address areas of concern in a deliberate and organized way. The CHNA must identify the sources of relevant clinical, demographic, and financial data associated with that population; the resources available to attempt to address population health needs; and the gaps in capabilities and resources needed to impact population health.

4.       Invest in diverse, patient-oriented access to facilities and IT infrastructure. Facilities should be designed to provide convenient care sites for patients and capabilities for outpatient, office-oriented care.  At a minimum, the IT system should be able to perform network-wide scheduling, provide patients with a portal to their own healthcare information, provide a patient-friendly means of communication with providers, and provide a virtual care interface for providers within the network.

5.       Perform data analysis that is aimed at identifying care gaps.   By integrating evidence-based medicine best practices garnered from national and local sources with the organization’s claims data and clinical data for chronic disease states, care gaps for individual patients and the population as a whole can be identified.  Clinical data will show what clinical plan was pursued.  Claims data will show what actually was done and the effectiveness of the care rendered.

6.       Stratify patients into risk groups.  Using data analytics, patients can be sorted into three risk groups: healthy, intermediate or rising risk, and high risk.  Resources can then be allocated toward the groups in ways that yield the greatest return on investment.  For instance, strategies advocating exercise and healthy eating can be implemented at low cost and have general application across all three groups.  Strategies designed to keep patients in the rising-risk category from moving to the higher-risk category should perhaps receive the most attention because of the higher return on investment that can be realized.  By taking advantage of new Medicare payment codes to pay for chronic care management, providers can now receive compensation for more proactive management of high-risk, high-cost patients.

7.       Engage and activate patients within the population to take responsibility for their own health.  The Patient Activation Measure, developed by Judith Hibbard, and the 43 engagement behaviors, identified by Jesse Gruman of the Center for Advancing Heath, is an excellent tool for engaging the population.  The effort must be aimed at both the population level (to address the community social determinants of health) as well as at the specific patient level (engaging the patient in decisions and habits that impact their personal health status).

8.       Place in motion a continually evolving and dynamic plan that incrementally begins to manage care for the population.  It should contemplate a team approach, led by the Organizational Hub, but employ the skills and resources of all the assets of the community in which the population resides.  Care must be coordinated across the continuum of care, specialized for the patients based upon the stratification of risk groups.  The healthy group should receive wellness and prevention programs; the rising-risk group will need frequent screening for the condition for which they are at risk and interventions to encourage lifestyle changes, and the high-risk group will need care strategies to prevent further complications of their disease or diseases (as is frequently the case).

9.       Consider an investment in a lean, scalable care team that can expand the physician staff’s capabilities to effect population health management and allow practitioners to practice at the top of their respective licenses, doing what they presumably like doing best.

Strategically deployed advanced practitioners can greatly improve patient interaction and relieve physicians of time commitments. An expanded role for pharmacists can accelerate access to care, monitor medication therapy management, and prevent readmissions to the hospital.  Robust extended-care resource teams can provide the necessary patient monitoring and interaction to effect lifestyle change and assure patient compliance with care plans.  The care team can be empowered to care, communicate, and coordinate – all keys to managing care.  An integrated behavioral health function can have dramatic impact on patients’ compliance with care plans and significantly assist patients with co-morbidities.

10.   Measure and compare outcomes with baseline data to demonstrate progress and success.  The basic IT system used will need the capability to identify clinical processes, care outcomes, cost of care, and patient satisfaction scores.  A system of continual process improvement will need to be implemented wherein the outcomes measured can identify areas that are capable of improvement so that the planning team can address those gaps and continue to advance capability and improve process.

Ultimately, population health is defined by the healthcare executives, clinicians, community stakeholders, and individuals comprising the population in question.  The definition emerges from the process of harmonizing the views and talents of those seeking to positively impact the population’s health status.  Each aspect of population health identified above – clinical, organizational, and technical – must be uniquely adapted to address the multiple needs of the defined population and the complexity of environmental factors within its community.

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