5 steps to population health management

Performance enhancement may be achieved through a multi-step approach.
By Jonathan Niloff, MD
04:10 PM
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In 2014, funding for digital healthcare technology companies reached $2.3 billion—surpassing the previous year’s total, according to Rock Health. This comes as no surprise as healthcare technology adoption has also steadily increased among providers in an effort to improve care and reduce costs, particularly around population health management.

Realizing the return on investment (ROI) from implementations of population health management technologies can take years. According to a recent KPMG LLP survey, providers noted that over half of healthcare managers expect to recoup investments in population health management programs in three to four years.

That said, there are approaches to optimizing programs for an earlier ROI. Processes will vary from organization to organization but for St. Vincent’s Health Partners, Inc. (SVHP), performance enhancement was achieved through a multi-step approach.

High-risk populations benefit

At SVHP, a Bridgeport, Connecticut-based physician-hospital organization (PHO), population health management was needed to manage the health of their attributed population, including high-risk patients in their southwest Connecticut community.

ONC officials note that having complete data on a patient is critical to achieving population health goals. Since SVHP’s PHO is designed to manage the total cost of care, it needed just that: automated, accessible data to coordinate care and select patients for care management and strong outcomes data to demonstrate the organization’s effectiveness.

After investing in and implementing a population health management program, SVHP experienced high-quality analytics, real-time feedback to their practices to maximize point-of-care services and enhanced ability to coordinate care across the organization. The independent PHO observed a decrease in out-of-network care, lower utilization with regard to ambulatory sensitive conditions and lower PMPM cost for highest risk patients.

5 steps to success

Physician-hospital organizations like SVHP or providers seeking improved ROI on population health management can follow these five steps to help ensure success:

  • Step 1: Connect: Acquiring, aggregating and leveraging data in support of clinical integration is a base competency required of providers seeking to adopt a population health model. This can be a challenge because healthcare data is often siloed in different systems across the care network, but it is a required foundation for population health to enable the sharing of patient data across the continuum to improve outcomes.
  • Step 2: Analyze: Once connected, financial and clinical data must be turned into usable information. Analytics is the foundation of population health management and successful risk assumption. Transforming data into actionable insights focused on improving quality and cost is the true value of healthcare analytics. Staff should focus simultaneously on looking for improvement opportunities at the population level as well as the needs of individual patients.
  • Step 3: Intervene: Analysis identifies members of the population who require intervention—whether that means closing preventive or chronic care gaps, generating a care plan or addressing what keeps a person from filling and taking prescriptions. For SVHP, intervention was required for their high-risk population.
  • Step 4: Engage: Population health solutions engage patients, physicians and other clinicians. Patient engagement is optimized when the patient is involved in a process of combining information and professional advice with his or her own needs, preferences and abilities. The goal is to make the best, personalized healthcare decisions and to allow patients to be partners in their care. Physician engagement requires physician buy-in, physician alignment with key metrics and organizational objectives as well as easy to use physician workflows.
  • Step 5: Support: Support services can help organizations implement and manage a population health program with new care models, processes and care teams to support new payment models. These services can encompass a variety of domains, such as helping to craft strategy, assist in practice transformation, provide staff augmentation or even provide a turnkey approach to population health management. With the ability to implement actionable analytics, accurate patient care registries and care management programs, organizations can exceed clinical and financial goals.

While one size doesn’t fit all, healthcare organizations can learn from St. Vincent’s Health Partners’ journey and apply the relevant steps to create a foundation to provide better, proactive care at a reduced cost through population health management.

Jonathan M. Niloff, MD is vice president and chief medical officer at McKesson Technology Solutions.