Population health is all about making people healthier while reducing costs for everyone. There are many examples of successful population health management initiatives that have proactively coordinated care for a specific population group. Traditionally, these programs have been carried out on a small scale for things like reducing hospital re-admissions, heart disease risk, or complications in diabetes. A new report by PwC called, “Population Health: Scaling Up”, talks about what is required to take these programs into the big leagues. The key is making the program scalable. The report lists 3 key steps for making population health programs scalable: client health risk assessment, care coordination, and using data-driven approaches.
Step 1: Health Risk Assessments
Conducting a health risk assessments is critical in order to ensure they get the appropriate care and treatment they need. Traditionally, many population health programs categorize patients by the financial risk they represent to the organization, grouping them based on their health needs and going no further. To scale programs successfully, organizations must focus on whole-person care that addresses the full social determinants of health that affect the health of individuals. This is where the health risk assessment comes in. It is impossible to know the full spectrum of a client’s needs and identify any barriers to care without first performing an assessment. According to Dr. Jessica Dudley, chief medical officer of Brigham and Women’s Physician’s Organization, “Identifying the patients who are the right fit for our programs is the biggest challenge, but also the biggest opportunity.”
Step 2: Care Coordination
Each patient has a different set of health needs and it is likely that your organization may not provide services for all of them. The PwC report emphasizes the fact that health systems need not approach population health management alone. “By coordinating patient care across different stakeholders within a network, health systems can ensure overall wellness activities for their patients are being handled on all fronts.” Relying heavily on care coordination across network players also helps health systems identify new care approaches they can incorporate into population health management.
“One mistake organizations often make is designing population health programs based solely on existing capabilities,” the report says. “While playing to their strengths in specific services, they should build their programs around the specific needs of their target populations and partner where they have gaps.”
A key trend in care coordination is the convergence of health and human service organizations in providing patient care. Public health agencies, social services, and behavioral health providers can help organizations identify environmental or lifestyle risk factors that could exacerbate health conditions. According to the report “To scale effectively, organizations should build an ecosystem of care that extends into the community – and into the home – by developing strong service-level agreements with partners that can fill their service gaps and extend their reach to patients.” However, one survey found that 68% of primary care practices are unprepared to manage patients’ social needs, and fewer than 50% say they coordinate with the right social service agencies. Collaboration between health and social service agencies is critical to population health program scalability.
Step 3: Create a Data-Driven Approach
Great organizations measure their true profit based on the distinct impact they are making and the effectiveness of the services delivered. Delivering evidence-based care plays a key role in achieving scalable population health management. If you are like many health organizations, you may be asking yourself:
- Where do I start?
- What are other population health programs doing?
- Do I have the right technology?
The broad adoption of electronic health records (EHRs) has given organizations a wave of data, but few organizations effectively pull meaningful information from that data. “Technology has been the answer to collect better data on our patients, but it can turn into a data dump for physicians,” said Dudley of Brigham and Women’s Physician’s Organization. Dudley continued “Population health programs should prioritize data efforts and focus on providing information to clinicians and their partners in manageable bites.”
The AIDS Foundation of Chicago is a great example of using data to drive a population health initiative. AIDS Foundation of Chicago utilizes data to track those living with HIV/AIDS and coordinate with other community providers to ensure there are no gaps in care. In September 2015, Karen Kowal, Director of CommunityLinks at AIDS Foundation of Chicago, presented a webinar where she discussed their innovative CommunityLinks program that targets high risk clients and results in better patient care, fewer hospital readmissions, improved population health, and reduced costs. That is a win-win for everyone. (Watch the full webinar here)
Eccovia Solutions is a firm believer in the vital importance of population health initiatives and the role they play in changing lives and communities. Collaboration among health and social service providers, powered by community-based case management, will be the key to building scalable programs.