Population Health Management

Three simple words, yet so much complexity

POPULATION Health Management (PHM)

Wikipedia defines population as ‘all the organisms of the same group or species, which live in a particular geographical area, and have the capability of interbreeding.’ Within the context of PHM, we create our populations using subsets of the big population. Possibilities are plentiful: ‘attributed Medicare members,’ ‘patients diagnosed with congestive heart failure,’ ‘patients with diabetes and obesity,’ ‘members of a self-insured health plan.’ With subsets established, we can then define our populations around two key elements: knowing who the patient is and have the appropriate data tied to that patient’s record. We then use ‘risk stratification’ to develop our care delivery and patient engagement models with two goals in mind – improving health outcomes and lowering costs of care. Understanding the numerous risk stratification models available is important. Having a strong data analytics strategy will put you in a better position to stratify risk across populations, then design, manage and measure your care programs and the outcomes for your populations.

Population HEALTH Management

If we look at what healthy means to each person, it’s different. Eat right. Exercise. Take your meds. Manage your stress. Don’t smoke. Wear sunscreen. It’s an individual decision to be healthy, but some people need help. The healthcare system needs to make it easier to be healthy. Changing behaviors and improving the health of populations requires us to share data about medications and understand the full scope of care along with a patient’s social determinants of health. We should leverage data already available, and understand its impact on the care solutions and approaches that aim to change a person’s behavior and promote a healthy lifestyle. Using and sharing data across the continuum of care is essential, as is exploring creative care models to address high-risk populations. Outcomes include improved care, an engaged patient and lower costs.

Population Health MANAGEMENT

MANAGING the health of a population requires the right organizational foundation for designing and deploying transformative models of care. But many organizations operate in a siloed, loosely governed environment, void of physician leadership in operational and informatics roles. They must move toward aligned leadership that includes engaged physician leaders across the continuum of care, along with a patientcentric view of processes and data. From here, leaders can develop care models and leverage evolving technologies to manage population health. Possible approaches include telehealth/telemedicine, remote patient monitoring and evolving staffing models associated with different levels of health risk. These all require a high-performing organizational culture where leaders can understand their costs and outcomes and take on the financial risk associated with advanced value-based reimbursement models, with these models extending up to executive compensation incentives. This diagram from AHIMA (American Health Information Management Association) clearly defines the many moving parts associated with population health management. Note the aligned, innovative organization at its center and its two key areas of engagement: provider and patient. Making the most of the relationship and interaction between physician and patient is about giving the provider the data, tools and processes they need to engage with their patients in a meaningful way that maximizes their health; a way that improves their health while minimizing the impact of an acute episode of care and/or chronic health condition. This engagement lies at the very heart of managing the health of a population – of Population Health Management.

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