Population health management 101: New strategies and tools to care for high-risk patients

03:00 AM
people sitting in a theater, population

By Miguel McInnis

Population health management has made significant inroads due to the emergence of various integrated delivery systems including patient-centered medical homes, hospital-based readmission prevention programs and accountable care organizations. It’s also become crucial as the industry rapidly transitions from fee for service to fee for value.

Population health is broadly defined as the health outcomes of specific groups of people, including the distribution of these outcomes within the group. These groups can be stratified based on large geographic areas or smaller groups of people, including: specific ethnic groups, people with certain chronic diseases, even inmates in a prison, and so on.

Pop health management also involves providing a wide spectrum of health care services that are directed at behavioral changes and encouraging healthy lifestyles to obtain optimal outcomes.

It is increasingly being used to target high risk populations. The pop health management approach exhibits a significant overlap with existing care management programs, but offers additional tactics to improve both clinical and financial outcomes of the target populations.

Evolving pop health strategies, and more complex care management interventions, are being deployed and integrated to help case managers who are directly engaged in health activities understand this changing landscape.

The Population Health Management Model

The main aim of pop health management is to improve health outcomes of groups of people by improving the quality of care, providing better access to care, and increasing preventive care. It has the potential to improve the health care system while at the same time making significant cost reductions.

The general model is based on utilizing teams of care givers such as care managers, attending physicians, a host of specialist providers, and the patients’ family members. One of the hallmarks of this model is its comprehensive nature and flexibility.

Pop health management has become more significant due to shifting reimbursement strategies, including performance-based compensation, and as more hospital resources are allocated to outpatient care in order to reduce readmissions.

But, the change in strategies to improve quality metrics across a stratified patient population requires stakeholders to leverage advances in technology, including identifying new or relevant metrics to measure outcomes of the target group, providing culturally competent patient support services, and using various forms of communication to engage patients how they want to be engaged.

Population Health Management systems are made up of several platforms:

Population Health Intelligence Platforms: Population health intelligence platforms are used to provide plan administrators and care teams with secure cloud-based access to comprehensive financial and clinical information. These platforms access clinical data and other patient data from multiple sources. They also give users easy access to predictive analysis, population risk stratification, hospital admission data, disease registries and referral data. The platform seamlessly connects to data warehouses that store third-party information and should allow third-party applications to be integrated to increase the functionality with ease.

Medical Management Systems: Medical management systems combine people and information to create highly personalized and effective services that are used to manage acute care management, chronic care management, wellness management and utilization management. Accurate integrated data is used by population health systems to identify at-risk patients, track results, analyze care and support wellness management. This helps patients experience fewer hospital and emergency visits.

Risk Stratification: Risk stratification tools are used to identify different population needs across all levels of risk and design the appropriate interventions to address the needs of the population across the entire continuum. These tools use demographics, care patterns, medical conditions and resource utilization to stratify patients into five main categories namely episode of care patients; high risk patients; chronically ill patients; healthy patients but with conditions and healthy patients. This information is used by medical providers in healthcare management and decision making.

Patient Engagement: Patient engagement services help in motivating patients to become partners in their own healthcare. The aim at building supportive and long-lasting relationships and use third-party data to identify patient needs and foster active relationships between PCPs or other healthcare providers and patients.

Predictive Analytics: Predictive analytics tools are used to model medical conditions within population to identify high risk patients long before they require expensive care. Analytics is a useful tool in budget planning, as well.

Better Patient Access: Healthcare technology has grown immensely in its ability to target high risk populations. One the most dramatic uses of technology to reach patients with poor access to care involves the implementation of telehealth. Telehealth is a broad term used to refer to advances in use of healthcare technology in practitioner training, deliverance of services and continuing medical education.

As you can see, there are many facets to a successful population health management strategy. It’s become increasingly clear from many industry shifts that organizations need new strategies and tools to effectively care for the risk-based world.

Miguel McInnis is the founder of McInnis & Associates, a healthcare management consulting firm.

This article was originally published on athenahealth’s Health Leadership Forum.

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