Terms like population health, accountable care and risk-based contracting may have seemed futuristic to many in the industry just a few years ago; however, today these concepts are in full swing thanks to healthcare reform. The adoption of risk arrangements, for example, is a train that has left the station and is only picking up speed. What was primarily a bi-coastal phenomenon just 18 months ago has now spread across the country. And the pace of adopting and planning for these risk arrangements is accelerating.

With this shift of risk to the health system, providers must be able to manage the health of the entire population — one patient at a time. As new as the concepts seem, there already are established best practices for strategically using IT to help support new care models and manage population health across the continuum.

Centra Health, Ochsner Health System and Mercy Medical Center all share their stories in this issue. They’ve learned that instead of fearing population health management, provider groups should embrace it as a way for payers to reward their ability to provide better healthcare quality and cost-efficient delivery.

Foundational Strategies to Manage Population Health

In general, there are two key strategies to successfully improve and coordinate care across multiple settings and manage costs.

  • Enterprise Registry Platform: Physicians, employed or independent, need an overriding platform where they can share data, collaborate with respect to the care of their patients and get the whole health system team on the same page to manage their patients with a common set of clinical guidelines. The first step to meeting this quality management objective is the implementation of an enterprise registry platform that allows everybody to communicate and share data across the network and manage their patients together.
  • Continuum of Care Data: The second key strategy is to manage the cost of caring for those patients across the full continuum of care. Implementation of enterprise intelligence tools can leverage claims data, for example, to help organizations manage drug costs through drug substitution programs, identify who their emergency room “frequent flyers” are and understand practice pattern variation to identify improvement opportunities. It helps organizations better understand the true cost drivers of care, and then intervene in a targeted way to manage those drivers across the population.

Managing Population Health

The idea of using information technology to help change people’s behavior to achieve better healthcare presents some major challenges. It’s not as much about implementing technology as it is aligning the organization around the health management strategies that will lead to success in the new era of accountable care. Success under the new model requires a focus on strategies to keep all of your patients’ care within your network, to proactively close gaps in care and to efficiently coordinate care in the most appropriate and cost-effective care setting.

First, get everyone on the same page: Too often we see a lack of alignment between the executive team that’s managing the accountable care part of the organization and the team managing the traditional hospital admissions under a fee for service model. They’re delivering mixed messages to their physicians and other administrators. To ensure success, get everyone on the same page so they’re delivering a uniform message to all of their stakeholders.

Second, engage your physicians: Another challenge in managing the transformation is physician engagement, especially, as these networks come together, among the more loosely aligned physicians. Physicians need to understand this new world, where managing care in a common way to a common set of guidelines and objectives will help them to realize the potential of improved quality and cost management.

Transforming Care Delivery

Pulling off the transformation boils down to: education, incentives, and most importantly, leadership. If you can get key leaders in the community on board, the others will follow. Then it’s all about making it easy by putting in place the processes and support mechanisms to enable physicians and the rest of the care-giving community to participate in effective population health management.

5 Keys to Managing Population Health

Below are 5 keys to success in managing the health of populations, especially patients with health challenges such as chronic conditions. Managing these populations can improve outcomes, and reduce readmissions and unnecessary care events.

  • Achieve organizational alignment. It is imperative that there is buy-in to a population management approach among all constituents and that everyone’s incentives are aligned.
  • Foster clinical integration for optimal care coordination across the full care continuum.
  • Use a disease registry to track patients with chronic conditions to ensure their care complies with evidence-based guidelines for their condition. When you identify gaps in care, implement patient follow-up or necessary interventions.
  • Identify high-cost patients and use health coaches to develop and monitor care plans for the sickest patients.
  • Leverage IT to integrate your clinical and financial data for a complete picture of your outcomes and cost of care for the population. Analytics give organizations the insights they need to focus on their best opportunities for improvement. Intervention programs are implemented most efficiently through automation. 
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About the author

Dr. Jonathan Niloff is Vice President and Chief Medical Officer, Population Health, McKesson. He was the founder and chief medical officer for MedVentive, which is now a part of McKesson. In his current role, he is responsible for the strategic development of population health analytics and solutions. Dr. Niloff has over 25 years of health care experience as a physician, medical director, professor, author and health care technology innovator.