Population Health Management

The Triple Aim in
Coordinated Care
Impacting Population Health
Presenter: Helen Dao, B.A., MHA
Dao Consulting Services, Inc.
www.daoconsultingservices.com
(201) 448-2046
helen@daoconusltingservices.com
September 29, 2016
Copyrigh(c)DaoManagementConsultingServices,Inc. 2016

—  Explain definitions and concepts associated with
Population Health and Population Health Management
—  The role of health analytics in population health
management
—  Identify where your organization is on a Population
Health Management (PHM)
—  Implement care coordination interventions to foster
better clinical outcomes across a population
—  Implement PDSAs Cycles to track population health
management quality improvement
Learning Objectives

What Is Population Health?
AHRQ Definition: An approach to care that uses
information on a group ("population") of patients
within a primary care practice or group of practices
to improve the care and clinical outcomes of
patients within that practice.

What Is Population Health?
AHRQ Definition: An approach to care that uses information on a
group ("population") of patients within a primary care practice or
group of practices to improve the care and clinical outcomes of
patients within that practice.
Special
needs
Asthmatics
Geriatric
Community
Diabetics
Gender
Ethnicity
Housing
Behavioral
Health
HTN

Have you Heard about the Triple
Aim?
The Triple Aim- is defined as 3
inter-dependent components:*
1.  Improving the health of a
population
2.  Improving the patients
experience of care
3.  Reducing the per capita
costs of care for
populations
*Donald M. Berwick, Thomas W. Nolan and John Whittington, doi: 10.1377/hlthaff.27.3.759 Health Affairs 27, no.3 (2008):
759-769 The Triple Aim: Care, Health, And Cost

Population Health Includes:
Improving health outcomes of the group as a whole by
identifying, monitoring and addressing the health need of
individuals within the group.
1.  Health outcomes for a defined group that is at risk
(based on agreement of metrics and measures of
health)
2.  Patterns of specific health determinants for the group
at risk
3.  A continuous integration of resources, procedural,
clinical, and IT infrastructure is essential to creating a
clinical integrated network to improve population
health*
*Adapted from “Using Technology to Optimize Population Health Care Coordination Outcomes. December 10, 2014 by Wendy Vincent, R.N.,
National Practice Director, Beacon Partners”Copyrigh(c)DaoManagementConsultingServices,Inc. 2016

—  Are outcomes clinically defined?
—  Do they include things like functional status, well-
being or specific health behaviors like diet and
exercise or smoking cessation?
—  Do they include nonmedical health determinants
like economic or housing status?
—  Are patients with a specific medical condition?
—  Are patients with particular demographic
characteristics, such as age or gender?
How to Define a Population or Group?
Adapted from “Population Health: The Risks & Rewards. February 10, 2014. Howard Larkin. Hospitals and Health Networks.”

Leveraging Technology
Analytics
—  Dashboard
—  Data on patient utilization (RHIO)
—  Routing eligible patients to programs
—  Report from Health Information Exchange (Clinical data)
—  Define the clinical data that you need to know and track

Creating a Framework
—  Identify specific capabilities to manage and coordinate
population health management.
—  Develop specific capabilities to manage and integrate IT
with analytics.
—  Develop a framework to integrate clinical networks and
care coordination.
—  Strategize the creation of registries based on clinical
outcomes and nonclinical.
Keep in mind that these changes may require significant
system reorganization.

Getting Ready for Population Health
Management
—  At an operational level organizations must change their
structure as well as workflows to implement PHM and
adopt new types of automation tools and reporting.
—  Setting clear and realistic goals and objectives. It is
helpful to keep in mind the Triple Aim of the Institute
for Healthcare Improvement: improve the experience of
care, improve the health of populations, and lower the
per-capita cost of care.
While population health is only one of these aims,
achieving that objective would help organizations attain the
other two.

Example of Health Registries
by MCPs
Integrating gaps
in care (i.e.,
HEDIS measures)
into the PCP and
care coordinators
workflow.

Example of Health Registry by
Condition

Example Use from Care
Coordinators
“I like managing the daily hospital admission PHM
registry. I visit patients at the hospital and identify needs
for care coordination and complete bottom up referrals for
the different CC programs.”
___________________
“I enjoy working with my PHM registry for colonoscopy
because I am able to identify patients that may have
misconception about the colorectal screening, and I refer
them to the RN for patients education.”

Some Challenges
—  Having accurate and timely information is essential for
population health management. This may include:
—  Access to complete medical records
—  Accurate physician billing records
—  Access to timely and accurate registries
—  Ongoing collaboration with other organizations
—  Defined collaboration with MCOs (Managed Care
Organizations)
—  Having different systems such as EHRs, labs, and different
vendors
—  Well trained staff
—  Lack of effective workflows
—  Lack of workforce
—  Reconciling multiple lists from different sources

The How…Clinical Integration at
Your Practice
—  Building an multidisciplinary integrated network
requires physician leadership to design and
implement team-based care models that make full
use of available care resources.
—  Ongoing physicians and staff education on
concepts including patient-centered medical homes
and care coordination.

…And the How to Steps to Care
Coordination
—  Making the best use of clinically integrated services
requires ongoing care coordination.
—  Reducing unnecessary hospitalizations and urgent care
in complex populations provides the greatest economic
returns, and this is typically accomplished through
intensive case management, disease management and
coordination of home and outpatient care

Example of Population by Care
Coordination Interventions

Example of Population by Care
Coordination Interventions, Cont.

Example of Population by
Utilization

Example of Population by
Utilization, Cont.

Example of Super Users Pop

TEAM Coordination Actions are
Defined and Routed by Program
Algorithms
Source: Himms – Transforming Health Through IT. 2015.

Population Health Management Workflow
QA/IS&collaborate&in&identifying&target&population&&
Registries&are&generated&&&distribute&based&on&specific&identified&subpopulations&
According&to&priorities:&
• Diabetes(
• Hypertension(
• Asthma(
• Heart(disease(
• Chronic(Renal(Failure(
• COPD((
• Substance(abuse(
• ADHD(
• Depression(
• Other((
Pop&2:&By&
Complexity&
Care&Coordination&
Registries(assigned(and(managed(
by(care(coordinators(to(activate(
outreach(activities(
Pop&3:&by&
Age&Group&
Pop&1:&By&
Disease&
Manage&chronic&conditions&+&
social&determinants&of&health:&
• Diabetes(
• Hypertension(
• Asthma(
• Heart(disease(
• Chronic(Renal(Failure(
• Serious(mental(illness:(
Schizophrenia/Bipolar(
Disorder(
• Other((
Care&Coordination&
outreach(activities(+(develop(
care(plans(
• Immunizations(
• Well(care(visits(
• Care(for(Older(Adults(
(COA)((
Pop&4:&by&Social&
Determinants&of&Health&
• Housing(
• Employment(
• Benefits(
• Health(care(services(
• Education(
• Support(system(
• Food(
• Safety(
• Other(
Care&Coordination&
outreach(activities.((Conduct(chart(
review(to(collect(data.(
Care&Coordination&
Patient(group(assigned(based(on(
nonclinical(needs(
Registry& Registry& Registry& Registry&

Example of Health Registries by
Disease & Priorities

How to Improve
—  Quality assurance of workflows and data are
important components of registry success.
The goals for quality assurance should be
established for each registry, and the efforts
made and the results achieved should be
described.
—  IHI uses the Model for Improvement as the
framework to guide improvement work.
—  Learn about the fundamentals of the Model
for Improvement and testing changes on a
small scale using Plan-Do-Study-Act (PDSA)
cycles.
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx

Now what?
—  Implementing Changes
After testing a change on a small scale, learning from
each test, and refining the change through several PDSA
cycles, now we implement the change on a broader
scale — for example, for an entire pilot population or on
an entire unit.
—  Spreading Changes
After successful implementation of a change or package of
changes for a pilot population or an entire unit, now we
can spread the changes to other parts of the
organization.
http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx

In Summary
—  Effective and continuous coordinated care is the key to
improving patient’s satisfaction, lowering health care cost,
and getting good at coordinating care for different
subpopulations needs in order to improve clinical and
nonclinical outcomes.
Let’s review:
—  The Triple Aim- is defined as 3 inter-dependent components:*
—  Improving the health of a population
—  By the use of PHM registries and integration of care
coordination intervention as well analytics
—  Improving the patients experience of care
—  Outreach, engagement, resources, and continuum of care
—  Reducing the per capita costs of care for populations
—  Preventing hospital readmission, duplication of services such as
labs, care coordination, etc

Q&A
Helen Dao, B.A., MHA
Dao Consulting Services, Inc.
(201) 448-2046 / (201) 686-7152
helen@daoconsultingservices.com

Population Health Management

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