Population health management initiatives are becoming more popular as hospitals recognize the urgency to respond to increasing healthcare costs, quality standards and alternative payment models. According to a survey by Health Data Management, 67% of healthcare executives had some form of an existing population health management program (from a sample of 200 individuals). As the model of Accountable Care continues to evolve, most healthcare providers will inevitably implement or expand some aspect of a population health management initiative in the near future.
In our previous post “Population Health Initiatives Needs to Take a Holistic Approach,” we commented on the findings of a joint survey from Health Research & Education Trust, Public Health Institute, and Association for Community Health Improvement describing the broad approaches hospitals are taking in developing population health programs. Whether the mission of hospital leadership is to manage all users of a hospital, improve chronic disease management, or concentrate on patients with which the hospital has financial risk, there are key components to these programs that must be used to ensure goals are achieved. At Connance, we not only recognize the value of hospitals engaging in population health programs but also recognize the extraordinary amount of time, money and resources it takes to develop robust and successful programs.
What are the five key components to successful population health programs?
- Develop realistic, scalable population health programs
All healthcare organizations seek to manage cost, quality, and patient satisfaction; however, it can’t be accomplished by detailed management of every single user in a hospital or health system. This approach lacks a realistic, achievable strategy and overwhelms stakeholders (frontline staff, management and leadership) resulting in frustration over programs that are too broad in scope, make minimal impact, and are unsustainable.
Recommendations: Scale programs to identify and define core patient populations that will demonstrate measurable outcomes (e.g., decreased A1Cs among diabetics who attend a diabetes workshop). Scalable initiatives are the foundation to all successful and growing population health programs.
- Identify social, economic, cultural, behavioral determinants of health
Much of what has been missing in population health programs is the identification of social determinants of health (social, economic, cultural, and behavioral) and how they affect a patient’s ability to access health services. Often patients who did not adhere to treatment plans were considered non-compliant or resistant to change. Over the last few years, due to growing recognition of socio-demographic and behavioral factors in accessing care, patients are now understood to be “at risk” for poor health due to barriers rather than “at fault.”
Recommendations: Value the holistic approach to caring for patient populations by recognizing the crucial role social determinants play in a patient’s life. Personalized treatment plans based not only on a medical diagnosis but the individual’s socio-demographic challenges will have a greater impact on patient populations.
- Identify barriers and assign appropriate interventions
Using socio-demographic and behavioral insight to risk-stratify patient populations will assist healthcare providers in delivering targeted and personalized interventions most appropriate for the individual patient. Insufficient transportation, little access to healthy food, and limited social support are just some of the barriers hidden from standard EMRs and charts. Patient-centered care plans supported by matching appropriate interventions to specific needs will improve patient engagement while delivering the positive outcomes organizations hope to achieve.
Recommendations: Strengthen interventions and resource allocation through actionable, patient-specific risk-stratification and analytics. Successful population health programs can only be accomplished when patients are engaged and have the resources needed to adhere to treatment plans.
- Build strong partnerships with community providers across the continuum
An organization’s responsibility to manage population health doesn’t stop post-discharge. Providers must reach beyond their four walls and develop effective partnerships with other providers and community agencies to build a cross-continuum infrastructure that will support population health endeavors. Neither patients nor healthcare providers can afford gaps in care.
Recommendations: Build a strong partnership with community providers for active communication and collaboration to promote healthier communities. Building community collaboratives and cross continuum teams (hospitals, skilled nursing facilities, home health agencies, community services, etc.) will ensure patients receive the services they need by minimizing gaps in care when transitioning through the healthcare delivery system.
- Continue outreach to high risk patients through care coordination efforts
Successful population health programs require continued attention to patients at risk for relapse and other adverse events. Patients (mostly those in high risk categories) benefit from ongoing interventions facilitated through care coordination. Continued follow-up efforts for every user of a hospital or health system can be daunting and wasteful. Care coordination teams must be able to focus their attention on those patients most in need of preventive services.
Recommendations: Utilize predictive analytics to risk-stratify patient populations so care coordinators can focus their efforts on patients with the greatest needs. Successful, sustainable population health programs must be resource efficient and targeted to populations truly in need of health intervention.