Healthcare Analytics, Population Health Management, Healthcare Big Data

Population Health News

Enacting Effective Strategies for Chronic Disease Management

By Jennifer Bresnick

How can providers turn population health data into meaningful chronic disease management?

- Hearing the words “population health management” probably brings chronic disease care to mind almost immediately.  Diseases such as diabetes, asthma, hypertension, and COPD sap billions of dollars from the healthcare system every year, and represent an enormous challenge for providers who are increasingly incentivized based on keeping these subpopulations out of the hospital.  From medication adherence apps to appointment reminders sent through the EHR, providers have a range of tools at their disposal to track, corral, and encourage patients to manage their own care.

population health management

How can providers leverage these technologies while employing effective management strategies that provide patient-centered, population-minded care?

Harnessing population health data

If there is a silver lining to the vast number of patients who are suffering from chronic diseases, it is the sheer volume of clinical data that they have produced, much of which is now available in digital formats that can be analyzed with health IT tools.  Disease registries, pools of Medicare and Medicaid claims, EHRs, and data warehouses contain critical information for identifying at-risk patients, stratifying needs, and targeting those who are due for preventative care.

Providers can harness these resources in several ways: by implementing their own clinical analytics and population health management technologies, and by teaming up with local or regional partners to identify disease hotspots, pinpoint socioeconomic concerns that may drive higher levels of chronic conditions, and perform outreach activities in conjunction with community pillars like schools or churches.

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“When it comes to developing an internal population health infrastructure, “systems need a broad and unified dataset with three advanced capabilities: a longitudinal population view, the ability to forecast contract performance, and an overall means to foster trust and confidence in the data,” states Luke Shulman, Principal Consultant at Arcadia Healthcare Solutions.

“Most organizations have the basic ability to provide a snapshot of their performance at a particular point in time,” he said. “Add enough of these data points together and the resulting trend starts to show the bigger picture for performance, including opportunities for improvement.”

Building a robust population health management infrastructure that focuses on chronic disease care may seem like a daunting task, but even if providers are unsure of how to extract and use their own EHR data, they can reach out to their payers for help.  As accountable care strategies start to pique the interest of cost-conscious insurers, they are becoming more willing to partner with physicians to contain spending.

“So if you’ve been given a group of diabetics from your payer, you are sharing risk to help manage those diabetics in a more costly, high quality way,” explains Peter McClennen, President of Population Health Management at Allscripts.  “You might just need to create care management protocols and communications with those patients, so that would be a great way to start off.”

Gathering the care coordination team

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Once the data is in hand, providers must figure out how they’re going to use it.  The first thing to do is set goals and expectations about any chronic disease management program.  While large integrated delivery networks like Geisinger Health have had significant success with dedicated care coordination managers, and some studies have shown that such personnel can pay for themselves within weeks of joining the team, other providers have to make do with what limited resources they have on hand.

Smaller organizations can make use of patient stratification features in their EHR to cut down on the need for extra hands, and can explore automated care reminders as a way to keep nurses or administrative staff off the phone for long hours.  Home monitoring equipment that automatically uploads data might also reduce the need for frequent in-person check-ups that take time and resources, freeing clinical staff to learn more about data analytics technologies while executing more effective targeted interventions.

For a strong care management team, providers may also wish to consider hiring an informaticist or data scientist with expertise in healthcare.  Data scientists can help to optimize EHRs for population health management, develop or deploy dashboards for simplified data reporting, and suggest strategies for quality improvement based on patterns they find in claims, clinical information, and federal measures.

Above all, providers must foster a culture of transformation and a willingness to change as healthcare shifts towards a patient-provider partnership.  Defining clear roles for the patient and for the care team will help to establish expectations on both sides, encouraging all stakeholders to work together to keep chronic diseases under control.

Deciding which patient engagement, adherence strategies will work

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A provider can implement all the health IT in the world, but effective chronic disease management will still rely almost entirely on the patient’s willingness to engage with their care strategies, take their medications, and show up at their appointments.  Devising patient engagement strategies that produce measurable results requires an intimate knowledge of the targeted patient population, an understanding of what drives non-adherent behaviors, and a familiarity with technologies that truly appeal to patients.

A patient population largely covered by Medicaid, for example, may face much different socioeconomic challenges than a privately insured community receiving support through their employers.  “Many of our members are very poor,” said Dr. Margie Rowland, Chief Medical Officer of CareOregon, while describing her organization’s population health program.  “Many of them have literacy issues, and they also have social issues that are impacting their ability to interface appropriately with the healthcare system.  That’s a pervasive issue in our population.”

“It’s not just about taking the right pills or coming back for appointments, but it’s making sure people actually understand their illness and understand what questions to ask, or getting help with transportation to their provider,” she added.  “It’s not just health literacy.  It’s literacy in general.”

Communities with a higher non-native English speaking population may require an investment in translation services, while a rural population could benefit from telehealth services that eliminate long drives and missed hours of work.

A recent study in a low-income, urban area found that text messaging was a surprisingly effective way to get the attention of patients who were in need of education on basic health issues. “This is a group whose attitudes and perceptions are incredibly important to understand, but who may not necessarily be taking online surveys or attending community meetings,” said Tammy Chang, MD, MPH, MS, an assistant professor in the department of family medicine at the University of Michigan Medical School and member of the Institute for Healthcare Policy and Innovation.

“We found that texting is not only acceptable and feasible but is the preferred method of collecting real time information from low-income community members.  Most importantly, texting may offer an efficient, inexpensive way to give a voice to people who aren’t often heard and whose needs aren’t always met.”

Providers should take the time to assess their patient population before committing to an engagement strategy.  Pairing healthcare data with feedback from the community will provide a useful foundation for future efforts and can save a great deal of financial investment that may just lead to a period of trial-and-error.

Healthcare organizations must also keep in mind the limitations of chronic disease management programs that rely on patients to take the lead.  For those who are seriously ill, have trouble with independent decision making, or would benefit from more intensive home care, a simple patient portal or periodic communication will not be sufficient to ensure good health.

“The tools necessary to assist the population really depend on the severity of the individual,” Rowland said.  “We have those who are dealing with chronic illness, and often with biopsychosocial issues, and they do need support, but then there are also those who are sicker who need more intensive interventions, so this is a piece of a more comprehensive strategy.”


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