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Can Population Health Management Team Up with the Community?

- Effective population health management goes far beyond what a healthcare provider can do for a patient in the office, argues Mark B. McClellan, Director of Health Care Innovation and Value Initiatives at the Brookings Institution in a blog post, and extends deep into the community.  Linking healthcare organizations with social services and community-based reforms is the best way to achieve pay-for-performance cost savings, prevent readmissions, and create a sustainable safety net for patients with complex health and social needs.

care coordination and population health management

Community-based healthcare providers, including federally qualified health centers (FQHCs) are already leading the industry in the adoption of advanced EHR technology and population health management software that allows them to stratify risk, identify patients who are overdue for preventative care, and send appointment reminders.  But McClellan believes that more work needs to be done in order to build strong relationships with external social service providers, including the transformation of payment structures into accountable care initiatives that encourage such alliances.

As a former Administrator of the Centers for Medicare and Medicaid Services (CMS) and former Commissioner of the FDA, McClellan’s promotion of accountable care as a key driver for population health might be unsurprising.  Despite mounting evidence that these strategies can effectively improve health and reduce costs, “many health care providers are reluctant to go down this path,” he writes.

“A hospital that invests in a community-based asthma program to teach patients how to manage their disease and avoid triggers, for example, may be able to prevent emergency room visits and hospital admissions by partnering with social workers or community health programs that can do family education and home modifications,” McClellan writes. “But to make such a reform sustainable, the hospital would need to shift its payments from Medicaid, Medicare, and private health insurers from paying for the asthma complications to paying for keeping asthma patients well.”

“This may be difficult, especially for hospitals that don’t have a well-integrated working relationship with social service providers, and for health insurers who would like hard evidence that these new payment reforms will really deliver on improving health and keeping overall costs down.”

READ MORE: CMS Picks Care Coordination Hubs for Accountable Health Program

Evidence is available on an anecdotal basis, from individual providers that have shouldered the burden of being population health pioneers.  The proposition is an expensive one, and building relationships with community service providers can be time-consuming.  Sometimes the neediest patients have so little contact with community organizations that they can be nearly impossible to find: the homeless, the indigent, or the migrant workers that show up briefly in emergency rooms or at temporary shelters but don’t routinely access care until a crisis hits.

“Collaborating with social service and community organizations also presents logistical and bureaucratic obstacles for clinicians,” McClellan adds. “For this reason, accountable care organizations (ACOs) have generally not made significant investments in non-medical, community-based prevention and wellness interventions.”

“Developing better evidence on health care reforms that bring health care delivery and community-based health improvement together is a critical policy priority,” he says.  “What evidence and changes in policy do health care payers and providers need to move forward with these reforms? Is it possible to develop better practical guidance for payers and providers on how they could implement such reforms now?”

“Through collaboration and shared accountability between hospitals, health systems, clinics, behavioral health services, community organizations and patients, it is indeed possible to shift our focus from episodic acute care to a holistic approach that keeps populations well. But we have a lot of questions to answer before these strategies will successfully transform health care and population health.”

Effective population health management goes far beyond what a healthcare provider can do for a patient in the office, argues Mark B. McClellan, Director of Health Care Innovation and Value Initiatives at the Brookings Institute in a blog post, and extends deep into the community.  Linking healthcare organizations with social services and community-based reforms is the best way to achieve pay-for-performance cost savings, prevent readmissions, and create a sustainable safety net for patients with complex health and social needs.

READ MORE: Do Providers Apply Population Health Management Inconsistently?

Community-based healthcare providers, including federally qualified health centers (FQHCs) are already leading the industry in the adoption of advanced EHR technology and population health management software that allows them to stratify risk, identify patients who are overdue for preventative care, and send appointment reminders.  But McClellan believes that more work needs to be done in order to build strong relationships with external social service providers, including the transformation of payment structures into accountable care initiatives that encourage such alliances.

As a former Administrator of the Centers for Medicare and Medicaid Services (CMS) and former Commissioner of the FDA, McClellan’s promotion of accountable care as a key driver for population health might be unsurprising.  Despite mounting evidence that these strategies can effectively improve health and reduce costs, “many health care providers are reluctant to go down this path,” he writes.

“A hospital that invests in a community-based asthma program to teach patients how to manage their disease and avoid triggers, for example, may be able to prevent emergency room visits and hospital admissions by partnering with social workers or community health programs that can do family education and home modifications,” McClellan writes. “But to make such a reform sustainable, the hospital would need to shift its payments from Medicaid, Medicare, and private health insurers from paying for the asthma complications to paying for keeping asthma patients well.”

“This may be difficult, especially for hospitals that don’t have a well-integrated working relationship with social service providers, and for health insurers who would like hard evidence that these new payment reforms will really deliver on improving health and keeping overall costs down.”

Evidence is available on an anecdotal basis, from individual providers that have shouldered the burden of being population health pioneers.  The proposition is an expensive one, and building relationships with community service providers can be time-consuming.  Sometimes the neediest patients have so little contact with community organizations that they can be nearly impossible to find: the homeless, the indigent, or the migrant workers that show up briefly in emergency rooms or at temporary shelters but don’t routinely access care until a crisis hits.

READ MORE: ACOs Increasingly Assuming Population Health Management Duties

“Collaborating with social service and community organizations also presents logistical and bureaucratic obstacles for clinicians,” McClellan adds. “For this reason, accountable care organizations (ACOs) have generally not made significant investments in non-medical, community-based prevention and wellness interventions.”

“Developing better evidence on health care reforms that bring health care delivery and community-based health improvement together is a critical policy priority,” he says.  “What evidence and changes in policy do health care payers and providers need to move forward with these reforms? Is it possible to develop better practical guidance for payers and providers on how they could implement such reforms now?”

“Through collaboration and shared accountability between hospitals, health systems, clinics, behavioral health services, community organizations and patients, it is indeed possible to shift our focus from episodic acute care to a holistic approach that keeps populations well. But we have a lot of questions to answer before these strategies will successfully transform health care and population health.”

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