This document summarizes a presentation on population health management. It defines population health management as focusing on keeping patient populations as healthy as possible to reduce costly medical interventions. It identifies key aspects of population health management including defining targeted populations using data, establishing an effective governance structure, using technology to accomplish goals, and integrating care through community partnerships. The document provides examples of how organizations can implement population health management strategies.

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Thank You
Presented by:
Wendy Vincent, National Practice Director, Strategic Advisory Services
HFMA Dixie Institute
February 19, 2015
Population Health Management:
What it Means For You and Your
Organization

2. Heading – Ariel 40
 Define Population Health Management
 Identify targeted populations
 Create effective governance structure
 Use technology to accomplish goals
 Establish realistic benchmarks
 Integrate care approach through
community partnerships
2
Objectives

3. State of Healthcare

4. Storm Factors
 Affordable Care Act: As of April 2014 – 8 Million Americans have
signed up for healthcare, shocking the system as they present to
PCP’s1
 Rapid Baby Boomers, everyday 10,000 people turn 65
 Reduction in Primary Care Physicians
 Increase in prescription drugs, contributing to higher costs and more
advanced treatments resulting in longer life expectancy
1) Familiar Physician, Dr. Peter Jackson

5. Heading – Ariel 40Top Concerns of Health Care Systems
5
1. What is the business model for population health?
2. Have I assembled the right network components?
3. Do we understand our patients as consumers?
4. What investments can we can make to help us with both
fee-for-service and value-based incentives?
http://www.advisory.com/Research/Health-Care-Advisory-Board/Blogs/At-the-Helm/2014/05/Four-challenges-every-leadership-team-is-talking-
about?WT.mc_id=Email|Daily+Briefing|Blog|HCAB|Jul-14-2014|||||

6. Why Is It So Important Now?
 Healthcare Payment Reform
• End of fee for service
• Value-based purchasing
• ACOs and PCMHs
 Reporting On Clinical Quality Is Retrospective
 Care Coordination – what do we need to do right now to produce the
best outcome for a single, particular patient
 Population Health – focuses on the future, what can we and should we
do in the future to produce better outcomes, higher quality and lower
costs
 Technology
• Broad EHR adoption
• mHealth
• Analytical tools

7. Population Health Management (PHM) Defined

8. Heading – Ariel 40Population Health
8
“The use of a variety of
individual, organizational and
cultural interventions to help
improve the illness and injury
burden and the health care use
behavior of defined populations.”
Dr. Michael Hillman,
Marshfield Clinic
“The health outcomes of a group
of individuals, including the
distribution of such outcomes
within the group”
American Journal of Public Health

9. Heading – Ariel 40PHM Defined
9
 Population Health describes the health outcomes of a group of
individuals, including the distribution of such outcomes within the
group. Population health outcomes are the product of multiple
determinants of health, including medical care, public health,
genetics, behaviors, social factors, and environmental factors.
 Goal: Keep patient population as healthy as possible and reduce the
need for costly interventions such as ED visits, hospitalizations,
imagine tests, and procedures.
 To support PCMH & ACOs, many organizations will need to start
implementing PHM to keep patient population healthier and reduce
costs.

10. Heading – Ariel 40PHM Framework
10

11. Heading – Ariel 40Patient Centered Medical Home
 Engaged leadership
 Quality improvement strategy
 Empanelment
 Patient-centered interactions
 Organized, evidence-based
care
 Care coordination
 Enhanced access
 Continuous, team-based
health relationships

12. ACOs
• Healthcare organizations are formulating
Clinically Integrated Networks (CINs)
• Network of Providers belong to ACO
• Physician metrics/scorecards are established
• Targets/Projections/Actuals – Shared Savings
• Population Health Management Systems are on
the rise for real time data

13. ACOs
 Complete & timely information about their patients and the
services they are receiving
 Technology and skills for population management and
coordination of care
 Adequate resources for patient education and self
management
 A culture of teamwork
 Coordinated relationships with specialists and other providers
 Ability to measure and report on the quality of care
 Infrastructure skills for the management of financial risk
 Commitment by leadership to improving value as a top priority

14. ACO Growth
14
http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/

15. Heading – Ariel 40CMS State Innovation Programs
15

16. Challenges to Overcome
 Technology Alignment with Business:
• Are we collecting the right data?
• Once we get it, what does it mean?
• How can we effectively use data?
 Organizational Strategy:
• My organization doesn’t have a clear strategy
• Our areas are like silos with their own information
 Process Changes:
• Each department has their own plan; roles and process
changes are needed towards a new optimal state but where do
we start?
 Lower costs:
• How can overall costs for defined Populations be reduced?

17. Identifying Targeted Populations

18. Heading – Ariel 40Identifying Targeted Populations
18
 What’s the best way to use our resources?
• Identify high risk
 Readmissions
 Repeat ED visits
 LOS
• Specific diagnoses
 Diabetes
 Congestive heart failure
 High blood pressure
 Asthma
• Geographic/population areas
• Community Health Needs Assessment

19. Heading – Ariel 40Identification Mechanisms
19
 Predict resource usage

20. Heading – Ariel 40Conditions Analysis
20
Screenshot from Caradigm Risk Management tool

21. Heading – Ariel 40Risk Assessment
21 Screenshot from Caradigm Risk Assessment Tool

22. Heading – Ariel 40Organizational Considerations
22
 What are your resources across the continuum of care?
• Case managers
• Transition of care program
• DSRIP efforts
• PCMH development
• Care coordination
• Community resources

23. Governance

24. Heading – Ariel 40Governance Key to Success
24
 Leadership endorsement of new staffing models and roles
 Define specific roles and responsibilities
How will you
communicate
efforts?
How will you
ensure care and
resources are
centered around
the patient?
How will you
involve the
community?
How will you
integrate efforts
into the continuum
of care?

25. Heading – Ariel 40Key Considerations
25
 Who will review and analyze data?
 Avoid redundancy and overlapping efforts
 Avoid silos
 What committees do you already
have in place?
• Quality committee
• Ambulatory care committees
• Policy and procedure committees
• Credentialing committees
 What has or hasn’t worked well in the past?

26. Technology

27. Heading – Ariel 40Effectively Using Technology
27
 Automate workflows for appropriate utilization of
resources
 Connect care team in coordinating patient care
 HIE
 Communicate via a portal
• Patients
• Physicians
• Affiliates and community resources
 Track and report data in timely manner
 Use appropriate metrics to evaluate the program

28. Heading – Ariel 40Example: Patient Portal
28 Screenshot from Allscripts FollowMyHealth™ patient portal

29. Heading – Ariel 40Primary Care
29
 Registry member
 Portal for EMR management
 Push alerts for recalls and
immunizations or upcoming
needs for blood testing
 Self-scheduling online
 Diabetes management

30. Heading – Ariel 40Care Management/Coordination
30 Screenshot from Caradigm Care Management Tool

31. Heading – Ariel 40Care Gaps
31
Screenshot from Caradigm Care Management Module

32. Evaluation Criteria

33. Heading – Ariel 40Establishing Benchmarks
33
 Gather data
• EMR
• Claims data
 Input critical
• Staff
• Patients
• Providers
 Evaluation techniques
• Timely data
• LACE index
• PHM tool
 Set realistic targets
 Where are you NOW
compared to your
benchmarks?

34. Integrated Care Approach

35. Heading – Ariel 40Connect with Your Community
35

36. Heading – Ariel 40Outreach Strategy
36
 Risk assessment
 Define population
 Define new roles and workflows
 Define issues to address
 Develop plan to target needs
• Education
• Counseling
• Preventative clinics/care
 Communication strategies to target underserved
populations

37. Heading – Ariel 40Integrated Care Example
37

38. Heading – Ariel 40Key Takeaways
38
 Develop PHM strategy and program
 Use data to define your populations (internal and external)
 Ensure your strategy aligns with organizational goals
 Create a governance structure to drive change and
accountability (new roles)
 Engage in Risk Model Programs (ACOs and MSSPs)
 Develop care coordination programs through new optimal
workflows (Re-admission programs, PCMHs)
 Use technology to automate processes
 Create an outreach approach to integrate care throughout
the community

39. Change is Hard
39

40. Heading – Ariel 40Questions?
40
Wendy Vincent, RN, is an accomplished healthcare executive with 30 years of
professional experience across all areas of healthcare. She has served in both
executive and senior leadership positions with academic medical centers and large
Integrated Delivery Networks. Wendy understands the unique opportunities and
challenges associated with optimizing people, process, and technology. She has
been successful with helping organizations identify areas to improve care quality,
increase operational efficiencies, and optimize revenue. Wendy is a strategic thinker
and planner with strong problem-solving and organizational skills. She is accustomed
to building relationships at all levels of leadership and staff. She holds a Bachelor of
Science in Nursing with graduate work in Nursing Education. She is actively involved
in nursing, clinical, and IT professional societies.

41. 1.800.4BEACON │ BeaconPartners.com
BOSTON · CLEVELAND · SAN FRANCISCO · TORONTO
Thank You
For more information
please contact
Thank You
wendy.vincent@BeaconPartners.com
Wendy Vincent