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POPULATION HEALTH MANAGEMENT:
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IHI NATIONAL
THE BUILDING BLOCKS
RESEARCH BY MARTY STEMPNIAK

A
FORUM s health care reform takes hold, hospitals are being entrusted with keeping the healthful healthy and carefully managing the
BOOTH 801 chronically ill across all settings, from hospital to home. Population health is the key in this new reality parsing patients into
different groups, analyzing data and targeting interventions.
Health care markets around the country are moving at varying speeds toward this new model, says Brian Silverstein,
M.D., president of consulting firm HC Wisdom. That may depend on how aggressively employers manage health care costs,
insurers willingness to experiment with new models, and the level of competition in a market.
Health care organizations large and small are realigning themselves toward managing the health of patient populations. Advocate
Health Care with its 10 acute hospitals has entered into $3.5 billion in contracts with various payers, based on the quality of care,
rather than number of visits. The Downers Grove, Ill., system is educating its employees about population health, aligning around common
measurements, refocusing primary care and coordinating service across the system.
Though smaller, 300-bed Greater Baltimore Medical Center, too, is repositioning itself as a community health system. Chief Executive
Officer John Chessare, M.D., says thats meant aligning loosely affiliated physician practices, and embracing advanced primary care to
According to the KLAS Population Health Management 2013: better coordinate all of a patients encounters with the health system. The smaller you are, the easier it is to get started, Chessare says.
Scouting the PHM Roster report, Conifer Health Solutions is
ranked as an early leader based on our portfolio of solutions. Most small hospitals also have a relatively small medical staff and a smaller population of individuals that theyre trying to cover. So, the
2014 Conifer Health Solutions, LLC.
real change is trying to get everyone on board with the vision, and rowing in the same direction.
This gatefold is sponsored by:
CONIFERHEALTH.COM
Revenue Cycle Management Patient Communications & Engagement Clinical Integration Population Health Management Financial Risk Management
2014 Conifer Health Solutions, LLC.
4 steps on the path
to population health
T
here are four steps that hospitals should take on their
journey to treating the health of populations, says Joseph
Damore, vice president of population health management
at consulting firm Premier Inc. Where hospitals are along that path,
and where they should be, varies from market to market. Damore
believes most are in the middle, developing their initial plan or
starting to implement it. Damore says health care is in the third
wave of interest in population health, and momentum is picking
up. Most organizations have now come to the conclusion that this
is not going away, and it doesnt matter politically, whether Demo-
crats or Republicans are elected. Were still going to move in this
direction across America.
PREPARATORY
Educating employees about population health
Assessing the organizations needs
Performing a gap analysis to see whats missing
Developing an operational plan
TRANSFORMATIONAL
Building up a primary care network
Instituting patient-centered medical homes
Integrating clinically with care sites across
the spectrum
Managing care of individuals
Developing networks
Utilizing health informatics
IMPLEMENTATION
Defining populations
Pursuing new payment models
Partnering with insurers
EXPANSION
After hospitals tackle one initial population in a
pilot, Damore says they often expand the concept
to other payer groups, such as:
Their own employee health plan members
The commercially insured
Medicare and Medicaid members
Employers via direct contracting
The uninsured
POPULATION HEALTH MANAGEMENT:
THE BUILDING BLOCKS
Building an infrastructure Its all about the metrics Three types of data The key components of your population health delivery system
A A
dvocate Health Care established nine steps in building its organizational structure to pursue population health, says ccording to the Health Research & Educational Trust, there are eight you should collect The various components that hospitals must have in their population health system can be separated into three buckets, according to Bob Edmondson, chief
1
Michael Englehart, M.D., president of Advocate Physician Partners. He emphasized staying transparent with physicians metrics that hospitals and health systems can gather to help gauge
strategy officer of Carroll Hospital Center in Westminster, Md. For the 193-bed nonprofit hospital, those range from out in the community, to within the health
DESCRIPTIVE system, and then to the post-acute world after discharge. Edmondson says it took Carroll three to four years to get all the physicians and moving parts of
along the way and setting realistic expectations for how long the process will take. Any investment you make is going the health of populations. Heather Jorna, vice president of health care What happened? the continuum in order, and to start realizing some of the benefits. Those include a 30 percent dip in readmissions after three years. Because of the lengthy
to take a period of time. You have to be realistic about how quickly it will bend the curve or youll start to see the impact. But Analyze the past timeline, he says other hospitals should start immediately, regardless of market conditions. Even though hospitals may not be under these payment mecha-
innovation at HRET, says gathering data and forging nontraditional partnerships
(i.e., readmission nisms now, were heading toward this, and we feel very strongly that they need to be getting their arms around this stuff now, he says.
it doesnt mean that you take a blind eye and keep going down a path. Were very metrics-driven, but we have to be realistic. are both imperative to population health. It really is about collaboration, mea- rates)
There are three different
surement and prioritizing based on whats most important to the community,
sorts of data that hospitals must have to OBJECTIVE: DRIVE CARE TO LOWEST COST AND MOST CONVENIENT SETTING
1 | Reaching a board and executive decision and aligning the organization and also what you and partners can have an impact on. You have to be resource-
You cant step into this model without the support of the board, and the executive team has to subscribe to it, pursue population health management,
whether youre going big bang or starting with a small shared savings contract. This is expectations-setting. ful and creative in the partnerships you develop.
according to Woodbury, N.J.-based Inspira
Its not a straight line. There will be bumps. There will be setbacks. There will be lessons learned.
Health Network. Those vary in the degree of
2 | Implementation and structure METRIC DESCRIPTION
difficulty to collect, but the greater the dif-
We had a running start because all of the people, intellectual capital and some of the technology were already COMMUNITY HEALTH SYSTEM POST ACUTE
in place. But after that, a traditional physician-hospital organization might not be able to pull off shared sav- ficulty, the more competitive edge they
2
ings because it doesnt have bench strength; it doesnt have the technology and experience. And so, you cant Summary Health-adjusted life expectancy at birth, Self-care Urgent care Skilled nursing
measures years of healthy life, disability-adjusted can add for an organization.
underestimate the financial needs. Its a big investment. Primary care/PCMH Emergency department Rehabilitation
life years, etc. Retail clinics Hospital Home care
3 | Accountable stakeholder leaders Specialty care
We have to paint a vision for people: this is where were at, this is where we think the market is headed and Inequality Mortality and life expectancy stratified ACCESS CARE TRANSITIONS
this is why were taking these steps. If you dont do that, its the burning platform conversation. People move measures by gender, ethnicity, income, education, DISEASE MANAGEMENT The team: Call centers, IT interface, Transition coaches, case managers,
social class, geography
3
based on two things: You either have to articulate that its burning and you better get off of the cinder, or Care managers, primary care retail clinics, urgent care, primary care, disease navigators, home care,
theres a better place to land going forward. and specialty physicians, specialists, ED, inpatient intake hospice, palliative care
PREDICTIVE
Source: Carroll Hospital Center, 2014
Health Percentage of adults and children self- advanced practitioners, PCMH,
What might happen?
4 | Systemwide teams with physicians in clinical practice status reported as being in poor health, young
Analyze the future physician-hospital organization PATIENT NAVIGATION LONG-TERM CARE AND REHAB
When youre as large as Advocate, youve got to make sure theres representation across the entire organiza- children exposed to second-hand smoke Disease navigators, Skilled nursing facilities,
(i.e., LACE risk-
tion, because you could win in one area and fail in another and, overall, the performance will suffer. There has BEHAVIORAL HEALTH case managers long-term acute care, inpatient rehab,
Psychological Percentage of adults in serious psycho- assessment
to be continuity and standardization. Psychiatrists, psychologists, social work- SNFists, case managers, transition coaches
state logical distress, in pain the past 30 days, tool)
PRESCRIPTIVE ers, law enforcement, CASE MANAGEMENT
5 | Conceptual framework thats widely vetted or who are satisfied with their lives
What should we do? government agencies, Case managers, disease navigators, HOME HEALTH
Advocate, not unlike a lot of other health care systems, was hospital-based. We had a growing number of doctors Analyze the actions substance abuse counselors transition coaches Home health, hospice,
who chose employment, but we tended to focus on admissions and discharges. What we found was that we needed Ability to Adults with a disability, and mean palliative care, transition coaches
(i.e., follow-up with a Source: Inspira Health Network, 2014
to go upstream and identify patients when they were still in an ambulatory setting and working with their physicians function number of days in the past 30 with limited WELLNESS
primary care doctor
to throw additional resources. On the back end, instead of discharges, we have transitions. While its important to activity due to poor physical or mental Doctors, educators, exercise consultants,
within two weeks of
get patients out of the hospital, were most concerned about where theyre going next. health dietitians, physical therapists,
discharge)
alternative medicine providers,
6 | Project management approach, using metrics and work plans Access to Percentage of the insured population local gyms
Youre never done. Youre always trying to tweak or enhance what youre doing. Its not business as usual. When health care with a designated primary care
youre doing population health and taking on risk, every day theres another curve ball. So, the importance of disci- physician
pline to be able to knock down projects and not run from one fire to the next cant be underestimated.
Clinical preventive Adults who have received a cancer
7 | Ongoing communication services screening, those with hypertension
That speaks for itself.
whose blood pressure is under control,
diabetic population with controlled The science of using data for population health management
W
8 | Commitment to implement within an established time frame hemoglobin A1C values, and children
1 2 3 4 5
younger than 3 who have received vaccines ith data in hand, theres a science that IDENTIFY A POPULATION PERFORM CREATE TARGET MEASUREMENT
If you make this commitment and you start to invest in these risk types of arrangements, patients are coming.
AND CREATE A REGISTRY ANALYTICS SEGMENTS INTERVENTIONS AND MONITORING
Your failure to execute is not going to be, for lack of a better word, forgiven with the payers. It really becomes hospitals and health systems can use to
mission-critical that you are realistic and you execute against your project plan. Cost of care Percentage of unnecessary emergency
department visits, percentage decrease in improve care for patient populations, says Risk contract (Medicare Health risk Preventive screenings Case management Quality
9 | Transition quickly to operations effectiveness and optimization ED costs, and percentage decrease in cost Brian Silverstein, M.D., president of consulting firm HC Advantage, commercial, assessment At risk Care management Cost
I would phrase it differently: Fail fast. If you make a mistake, you have to recognize it and move on. Thats not of care per patient each year Medicaid, employer) Claims data Chronic disease gaps Social workers
the end of the world, but you cant stay in a model or a business plan that is not effective and not be willing to Wisdom. Having a population thats tied to an insurance
Fee-for-service contract Clinical data in care Medication reconciliation Source: Brian Silverstein,
tweak it or modify it, and thats one of the things weve learned. You just have to be willing to be very analyti- product is a key first step. with attribution (Medi- Lab results High cost Transitions in care HC Wisdom, 2014
cal and step away from a decision you thought was right two years ago, and now you have to come back and Source: The Second Curve of Population Health, HRET, 2014
care, commercial) Pharmacy Referral management
revisit it.
Remote monitoring