Population Health Management

The Population Health Model

5 Steps Toward Success in a Value-based Structure

Step 1: Connect

Acquiring, aggregating, and leveraging data in support of clinical integration is a base competency of providers seeking to participate in a population health model. This can be a challenge because healthcare data is often siloed in different systems across the care network. Population health typically leverages data from practice management systems, paid claims, laboratory, pharmacy, and electronic medical records. Organizations must also build a foundation of connectivity to build longitudinal patient records that properly match patients across these diverse data sets.

Step 2: Analyze

Once connected, financial and clinical data must be turned into usable information. Enter healthcare analytics. Analytics is the foundation of population health management and successful risk assumption. Organizing the data into actionable insights around opportunities for improving quality and cost is the true value of healthcare analytics. Key network analyses for a population health model include:

  • Predictive modeling to stratify patients by clinical and financial risk so that the appropriate level of care management is put toward the level of risk
  • Patient cost and utilization across episodes and medical conditions to give a full picture of the patient
  • Identification of patients not in compliance with evidence-based guidelines, providing the ability to identify gaps in care that can be addressed by the care team to improve patient outcomes
  • Patient registries to track all patients with respect to specific conditions and recommended care guidelines, ensuring coordinated care across the network
  • Provider practice pattern variation analysis to identify outliers by episodes or by utilization in different departments, providing the focus needed to work with and educate physicians on how to deliver evidence-based, cost-effective care
  • Network management analysis with respect to network leakage and physician referrals
  • Opportunities to optimize network performance across key risk contract success drivers
  • Modeling and management of physician incentive programs

Step 3: Intervene

Population 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. The population health model allows organizations to create care coordination and care management workflows to proactively drive intervention activities such as:

  • Point-of-care management of gaps in care
  • Integrated assessments, integrated care plans across multiple conditions, and care plans for transitions in care
  • Rules-based workflows to prioritize care management activities
  • Escalation and de-escalation workflows across the patient population, from the complex chronic patient to the well patient

Step 4: Engage

Population health solutions engage on three levels: patients, physicians and other clinicians, and the provider network.

  • Patient engagement signifies that a person is involved in a process of combining information and professional advice with his or her own needs, preferences, and abilities in order to optimize health and healthcare decisions. In the context of a population health model, strong patient engagement is about activating patients to produce better clinical outcomes. Toolsets to promote this include:
    • Outreach: Notify patients of a gap in care with a recommended call to action
    • Extension of care management: Help patients remain engaged with their care plan when they are not directly interacting with the care team
    • Patient education and behavior change: Offering tools and content that educate patients about their conditions and encourage healthy behaviors
    • Maintaining wellness: Promote healthy behaviors in a population to prevent the long-term development and progression of disease burden in individuals
  • Clinician and physician engagement is also comprised of three parts:
    • Physician buy-in is critical for fostering practice transformation. As such, careful rollout of a population management strategy is important and typically most successful with a physician leader as a champion
    • Ensuring physician alignment with the validity of key metrics upon which physicians will be measured is paramount. This includes data validity, proper physician attribution of patients, and acuity adjustments. Only then will physicians become more deeply involved in the measurement process and engage in desired behaviors
    • Easy to use physician workflows are fundamental to promoting adoption. The right information must be available to the right person at the right time to achieve the quality outcomes and increased efficiency for which the network or payer strives
  • Network engagement involves the proactive steering of patients to most appropriate lower-cost care settings for the clinical need, without compromising quality. For example, strong network management would encourage that a patient with the flu be seen in urgent care rather than the emergency room. Additionally, network engagement involves data-driven management of referral patterns, which can help networks more intelligently contract

Step 5: Support

Provider networks must make substantial investments to support the transformation into a value-based population health model through a broad range of advisory, operational, and care coordination services. These services should lay the foundation for care models, the care team, payment models, and organizational processes. Services could 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.

Next: Creating a Clinically Integrated Network

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