- Population health management encompasses a wide and varied range of activities, including care coordination, chronic disease management, health information exchange, patient risk stratification, clinical analytics, community outreach, and internal quality improvement. With so many different ways to approach what is basically a large-scale revolution in the way healthcare organizations views their role in patient care, it’s no wonder that many providers find it difficult to know where to begin.
What are some of the ways providers can start to build a population health management program that will produce better patient outcomes without breaking the bank?
Clarifying goals and developing a roadmap
Despite the national prevalence of familiar chronic diseases such as hypertension and diabetes, every provider serves a unique patient population with its own specific needs. Each provider also faces its own internal challenges, whether it’s a shortage of nurses, a bevy of competing initiatives, or a need to boost quality scores, and so “population health management” will mean something slightly different to each organization that takes on the task. Establishing an individualized set of targets and goals is crucial to success.
Providers may wish to conduct a preparedness assessment that includes a survey of available IT and staffing resources, an overview of current data assets and quality, and the key features of the patient community. Organizations would also do well to develop a series of benchmarks that can be used to measure progress towards established goals in order to stay on track and provide staff members with a clear sense of accomplishment.
Resources from organizations such as the American Academy of Family Physicians, the ONC, and the eHealth Initiative can serve as helpful guides for healthcare providers looking to develop their own action plans.
Infrastructure investments and data analytics
Once the path is in focus, providers will no doubt need to make some significant investments in technology that will help them get to their ultimate goals. The vast majority of hospitals and a good proportion of physician practices have already made the leap to EHRs, which can be an incredibly powerful tool for population health management, but additional solutions such as data warehouses, local or state-level health information exchange, and clinical decision support tools can add some serious firepower to an analytics program.
“Providers need to embrace EHRs for the purpose they serve. At the same time, however, it’s important to support approaches that turn data across the health system — both inside and outside of EHRs — into a strategic asset to improve the quality of care, the patient experience, and the outcomes for patients and populations,” said Brian Drozdowicz, Vice President of Population Health for Caradigm.
Healthcare organizations don’t need to dive straight into a multi-million dollar process of ripping out and replacing all of their health IT systems at once, however. While interoperability with multiple infrastructure components remains one of the top challenges of population health, more and more vendors are creating plug-and-play products that can build off each other to create a health IT platform one affordable piece at a time. Even the smallest steps can produce significant financial and quality returns – if the entire organization is committed to making them.
Engaging your staff members
Retooling a practice to embrace population health management as a fundamental principle of care can be a daunting change for clinicians and administrative staff members who already feel overwhelmed with cramming in enough patients in a day to keep the lights on. They may require some formalized education about the benefits of patient-centered, data-driven care, as well as some instruction on how to improve data integrity through clinical documentation improvement, how to leverage data exchange and care coordination, and even how to interact with patients while making the best use of EHRs.
Physician and nurse satisfaction with healthcare technology is at an all-time low, yet clinicians remain committed to providing high-quality care to patients while achieving recognition for a job well done. Educators may wish to entice physicians into learning new software or changing their workflows by appealing to their competitive nature. Scorecards and benchmarks that pin performance to financial bonuses or compare staff members to their peers may be an effective way to egg on physicians to new heights.
Engaging your patients
Patients, too, must be given incentives if they are to cooperate with care strategies that require more effort than they are used to. While the reward for the patient is better lifelong health and fewer hospitalizations, adding a bit of financial sweetener has proven to be an important method for success.
“This is important to anybody who bears the risk, whether they are governments, payers, self-insured employers, or the provider community,” said Michael Dermer, Chief Incentive Officer at Welltok. “With the exception, maybe, of the really, really, ill, there are always behaviors you can ask people to take, whether they’re generally healthy and have zero risk factors or they’re folks who have some chronic conditions.”
“If you’re talking about something simple like getting somebody to visit their primary care provider, that’s a pretty basic level of effort, right? I’m not asking you to change your eating habits or exercise every day. For that type of activity, $50 will be enough to get 40% of the people to do it. On the other end of the spectrum, to reduce your BMI by ten percent, you might need $250 to get the same percentage result.”
Ensuring care coordination and follow-up
Once patients are engaged, providers need to keep them that way. Ensuring care coordination as patients transition between care settings, maintaining medication adherence at home, and monitoring chronic conditions with the help of mobile tools like smartphones or home monitoring devices like Bluetooth-connected scales and telehealth consults is a critical piece of the population health puzzle. Providers should not forget to add post-encounter follow-up into their roadmaps if they are to follow a patient from initial identification of their needs to recovery and wellness after providing quality services and compassionate care.