Population Health Management

The Population Health Approach

What is Population Health?

The goal of a population health approach is to foster better clinical outcomes across the community and lower the total cost of care.

Traditionally, healthcare has been rather disconnected across settings and providers from both an IT and a process perspective. This makes it challenging to achieve coordinated care, often to the detriment of the patient.

In contrast, a population health approach is patient centered and goes back to the goals of what providers and payers all want to do well—the Triple Aim:

  1. Improve the patient experience of care (quality and satisfaction)
  2. Improve the health of populations
  3. Reduce the cost of care
A visual diagram of the population health approach that answers the question “what is population health?”
A population health approach uses data from across the healthcare continuum to improve quality of care while gaining efficiencies and reducing cost.

The population health approach provides tools to support the care team as they engage the patient to drive behavioral changes and ultimately better health.

Population health management improves quality of care and lowers cost by:

  • Identifying individual patients and patient populations who are most likely to benefit from intervention to proactively enable better care. For example, patients who are at a high risk for hospitalization
  • Managing transitions of care, such as hospital discharge, to support the whole patient and prevent unnecessary readmission
  • Matching patients with an appropriate care team of primary care physicians and specialists who are focused on both treatment and prevention
  • Identifying problems early on can significantly reduce cost by preventing the need for expensive tests or future hospitalization
  • Ensuring physician engagement with evidence-based care plans to reduce variation and inefficient or costly approaches to care
  • Effectively managing a provider network to identify opportunities for cost improvement, such as in the areas of pharmacy, imaging, and network leakage
  • Fostering quality improvement through identification and closure of evidence-based gaps in patient care
  • Providing transparency to quality compliance on a real-time basis to make adjustments as needed

The population health approach requires fundamental changes to the focus, technology platform, and delivery models of provider networks, including:

  • A care model strategy of how to implement value-based care delivery at scale across your network:
    • What are the rules of engagement?
    • How will you deploy your resources?
    • What best practices will you adopt with respect to both quality and utilization?
    • How will the care model vary for different patient populations?
  • A strategy that focuses on key goals with respect to targeted patient populations and success measurement
  • Shifting the organizational mindset from a solely hospital or physician office view to a full network view encompassing a variety of care settings such as long-term and urgent care
  • Building a more holistic view of patients through a scalable connectivity foundation to share data and analytics across the care network
  • Change management investments to gain credibility with physicians both with respect to strategic vision and, importantly, the data
  • Setting up the right governance processes, incentives, training, and organizational structure to engage physicians and the broader care team in the right way

Next: The population health model

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