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Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
Lancaster General Ppt Final
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Lancaster General Ppt Final

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Presentation on Population Health Management at Lancaster General Health 11/2011

Presentation on Population Health Management at Lancaster General Health 11/2011

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  • Patient self-management education. With the help of printed and online materials, care teams help patients learn how to manage their own conditions to the extent possible.Focus on health behavior and lifestyle changes. Providers and the educational materials offered can reinforce the need for healthy lifestyles across the population.Interoperable electronic health records. EHRs are used to store and retrieve data, not only on individual patients, but on the status of the population. They are also used to track orders, referrals, and other care processes to ensure patients receive the care they need. And by exchanging data with other clinical systems, interoperable EHRs provide physicians with information that help them make better decisions.Electronic registries. Whether or not registries are part of EHRs, they are important components of PHM, because they enable caregivers to track and manage all of the services provided to or due for their patient population, as well as subgroups of that population.
  • Nurseline – 24/7Private labeled, toll-free serviceURAC accredited call centerWelcome call to every householdCustomized scriptingBilingual specialistsMore than150 additional languages servedTriage calls diverted to lower cost optionsDigital recording of all calls
  • The widespread development of ACOs, perhaps with medical homes at their core, would provide a powerful impetus for a shift from the current care delivery model to PHM. With the backing of large organizations and the introduction of financial incentives that encouraged an outcomes-oriented, patient-centered care model, PHM could become the dominant model of healthcare.To increase access to primary care, we need to make use of “disruptive innovations,” including retail clinics, employer-based wellness programs, home telemonitoring of patients with chronic conditions, and new methods of educating patients in self-management (Lawrence
  • Transcript

    • 1. Population Health – The Myths and Realities ofAchieving a Healthy Community Lancaster General Hospital November 17, 2011 Steven Peskin, MD, MBA, FACP EVP and Chief Medical Officer, MediMedia Associate Clinical Professor of Medicine, UMDNJ
    • 2. 2
    • 3. Major Issues with the US Healthcare System• Poor and uneven access to medical care, especially for the uninsured• Escalating costs and volume of services• No link between cost and quality• Excessive administrative costs• Dysfunctional payment system• United States is lagging internationally in health outcomes
    • 4. Real Reform: Real Leadership1. The missing link is links!2. Comparative outcomes are all relevant and visible to patients.3. Many treat, few prevent.4. Create a culture of health.
    • 5. Real Reform: Real Leadership Current Approach New Approach---------------------------------------------- ----------------------------------------------Focus on current medical problem Focus on all risksPrimary care physicians Cooperative team of providersCare based on periodic visit Continuous healing relationshipsShort visits with little information Emphasis on education & coachingDecisions by clinical autonomy Evidence-based decisionsInformation restricted Electronic information flows freelyOne size fits all Care customized to needs & valuesPatient a passive participant Patient/family active participants
    • 6. The Concept of Population Health Management• PHM programs are a set of interventions designed to maintain and improve people’s health across the full continuum of care –from low-risk, healthy individuals to high-risk individuals with one or more chronic conditions.• Populations targeted by PHM are often delineated by health benefit source rather than geography. However, some proponents argue that because improving population health is a national goal, a target population can also be identified broadly, as in “all citizens of the United States,” as well as narrowly, as in “all people who call Dr. Jones their doctor” (Berwick et al. 2008). 6
    • 7. Conceptual PMH Framework 7
    • 8. The Conceptual FrameworkPopulation health is person-centered; organizationalinterventions are tailored to the individual and communityresources are targeted to individuals. Individuals areevaluated to identify their place on a continuum of healthrisks, from no or low risk to high risk. Specificinterventions, such as health promotion and wellness, riskmanagement, care coordination/advocacy, anddisease/case management, are targeted to people basedon where they fall on the continuum of risk/care. 8
    • 9. Aspects of PHM Cont’d• Patient self-management education• Focus on health behavior and lifestyle changes• Interoperable electronic health records• Electronic registries 9
    • 10. 10
    • 11. 2011Lancaster, PASnapshot 11
    • 12. 2011 Snapshotcomparison ofLancaster Countyvs. the MOSTHEALTHY(CHESTER) andthe LEASTHEALTHY County(Philadelphia)County in PAwhen comparingHealth Factors 12
    • 13. 2011 Snapshotcomparison ofLancaster Countyvs. the MOSTHEALTHY(UNION) and theLEAST HEALTHYCounty(Philadelphia)County in PAwhen comparingHealth Outcomes 13
    • 14. Population health engagement – menu of options • Worksite • Physician’s Office • Hospital Screenings • Other Clinical Facility • At Home • Lab option Target • Telephonic Health Coaching addressing lifestyle and chronic Programs conditions • Mail based programs • Onsite programs • Communications • E-messaging Population • Online Programs Programs • Campaigns • Warm transfers/ HA • Health Plans Referrals • Employers • Physician’s • Other Providers 14
    • 15. The Three Pillars of Engagement 15Source - Staywell Health Management 2011
    • 16. Obstacles to PHMIn the U.S., the biggest barriers topopulation health management are:• Fragmentation of care delivery• Misaligned financial incentives• Lack of managed care knowledge• Insufficient use of health information technology 16
    • 17. Three Pillars of PHM• To execute on the promise of PHM, physicians and their care teams must strengthen their relationships with patients in a variety of ways, including making sure they come in for needed preventive and chronic care. Care teams, which include physicians, midlevel practitioners, medical assistants, and nurse educators, must optimize the services they provide to patients during office visits. And as a coordinated team, they must extend their reach beyond the four walls of the office to provide a continuous healing relationship. The appropriate IT tools can facilitate achievement of all three goals while lessening the burden on practices. 17
    • 18. The Beginnings of Change• Over the past 15 or 20 years, approaches such as pay for performance and disease management have had a limited effect on quality improvement.• More promising models have emerged in the past few years. These include: – Patient-centered medical home (PCMH) – Accountable care organization (ACO). 18
    • 19. Patient Centered Medical Homes• While much progress is being made on the PCMH, practices that try to become medical homes can encounter obstacles. – Small primary-care practices may lack the time and the resources to transform themselves and acquire the necessary information technology (Nutting, Miller, et al.). – They may find it difficult to gain the cooperation of specialists and hospitals. – Physicians may not receive adequate financial support from payers for coordinating care (Landon, Gill,et al.). 19
    • 20. Accountable Care Organizations• ACOs consist of hospitals and physicians that take collective responsibility for the cost and quality of care for all patients in their population.• ACOs may be single business entities, such as a group- model HMO or an integrated delivery system. But they could also involve an “extended medical staff” or a contracting network that includes a healthcare system.• Core of ACO’s may be medical homes• ? The future of population health management 20
    • 21. The Promise of Population Health Management:Crucial Role of Automation• What is also needed for successful PHM is an electronic infrastructure that performs much of the routine, time- and labor-intensive work in the background for physicians and their staffs. Tools exist but are underused.• Technology is not a substitute for the physician-patient relationship. But to the extent that automation tools are used to strengthen that relationship, technology can help drive population health management. 21
    • 22. The Promise of Population Health Management:Crucial Role of Automation• In order to be able to effectively manage all aspects of health from wellness to complex care, healthcare organizations must assess the entire population, taking advantage of online or web-based programs.• Patients can then be stratified into various stages across the spectrum of health. – Those who are well need to stay well by getting preventive tests completed – Those who have health risks need to change their health behaviors so they don’t develop the conditions they’re at risk for – Those who have chronic conditions need to prevent further complications by closing care gaps and also working on health behaviors.• Technology can be very helpful in assessing and stratifying patients and targeting interventions to the right people. The automation of the processes provides a more efficient and effective way to do population health management. 22

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