Population health requires engaging patients and populations in a broad range of services and activities to prevent disease, improve the long-term success of medical interventions, increase the overall health of a defined beneficiary set and, ultimately, enhance the health status of all the communities served. Those academic medical centers (AMCs) that have implemented population health characterize their approach as incorporating five characteristics:
- Patient-centered, ensuring patients are engaged in the entire process of care and decisions are well informed, as well as recognizing the needs and preferences of diverse patients.
- Community engaged, partnering with communities to identify and meet the needs of those they serve and measurably improve overall community health.
- Primary care based, having patient-centered medical homes as foundational elements for patient engagement and using shared clinical information and protocols to link specialists, hospitalists, long-term care and nursing homes, and home- and community-based service providers. Specialty care medical homes are emerging as important vehicles for limiting care fragmentation in specific populations.
- Health IT enabled, linking patients, caregivers and providers to health information to help prevent illness and manage care in a coordinated model, as well as to support targeted quality initiatives.
- Academic, including residents, medical students and other health professional students in efforts to support patient health and identify research opportunities that may provide new approaches for improving health.
AMCs demonstrating a commitment to these objectives contrast sharply with those that focus almost exclusively on the highest acuity patients. That focus will remain a necessary but insufficient condition for success in the long term.
A particular challenge will be developing an ample network of primary care physicians and a community-focused system that can provide the comprehensive, longitudinal care chronic and elderly patients will require for decades. AMCs have always been a locus for complex and specialized care, but managing the health of individuals and populations across the entire continuum will be a new skill for many.
Managing an AMC’s Own Employees
Many systems begin by managing their own employees’ healthcare, allowing them to develop care management approaches, as well as to identify ways to improve outcomes and lower cost of care. They then can apply what they learn to create targeted products for nonemployee beneficiaries.
The University of Michigan Faculty Group Practice provides an example of this “employees first” approach through its participation in the Medicare Physician Group Practice (PGP) demonstration. The Faculty Group Practice built a complete care management system to address the entire disease spectrum.
In the first year, the Faculty Group Practice addressed common issues, such as missed appointments and incorrect use of medications, through a call-back program. In the second year, it focused on geriatric patients, expanding its presence into selected sub-acute care facilities. It also launched a palliative care service, expanded disease-specific registries and implemented IT tools to measure quality and cost performance. In the fourth year, it created a medical home infrastructure. By the conclusion of the fifth year, it was closely managing every high-risk group, including dual eligibles, frail elderly, at-risk patients in transition and patients needing palliative care. These initiatives earned the University of Michigan Faculty Group Practice the distinction of being the top performer in the PGP demonstration.
Partnering to Create a Networked Model
Some organizations are creating regional approaches, partnering with several systems across regions to care for large populations of patients. The University of Iowa has formed the University of Iowa Health Alliance to serve as an umbrella for numerous initiatives. Sharing and employing best practices across the network, the Alliance has statewide reach. Members can realize savings by sharing potential costs related to population health management. Alliance participants also have partnered to offer an insurance product on the state health exchange starting in October 2013.
Understanding that Information Technology is Fundamental
To achieve the goals of a population health model of care delivery, clinicians need access to sophisticated information management tools. AMC leaders must have complete insight into their organizations’ portfolio of clinical, administrative and financial data, linked together and used to drive high-quality, patient-centered care. Specific information management tools include:
- Registries and population health management tools that offer point-of-care and back-office clinical decision support, as well as workflow applications to maximize intervention impact and patient management. Particularly important is the ability to assess individual and group health risk accurately and dynamically—and prepare interventions and case management accordingly.
- Geo-mapping that supports community dialogue by linking claims data, emergency department and other use rates, crime statistics and additional relevant social and healthcare information to identify “hot spots” and target interventions.
- Health information exchange technology that seamlessly integrates clinical and financial data from all sites of care.
- Patient engagement tools and services that assist patients in active home care and support shared decision making in medical treatment scenarios.
- Quality measurement and reporting that demonstrates outcomes to purchasers, as well as enhances clinical behavior around evidence-based guidelines and best practices.
- Electronic health records that enable consistent, portable patient information across the entire patient network.
- Advanced analytics that identify costly, at-risk patients, so proactive, specific interventions can be employed.
AMCs must create new organizational capabilities and training programs for clinicians and staff to leverage these tools fully. They also must develop the capacity to manage chronic diseases in low-cost settings in the community, empower patients to manage their diseases more effectively and equip them to prevent emergency room utilization and hospital admissions. While AMCs must improve patient safety initiatives, particularly in inpatient facilities, they also must engage more broadly in preventive medicine to an extent previously unseen in most AMC settings.
Deciding Whether to Build or Buy
Population health management capabilities require significant investment to secure the right technology and human capital, develop the correct processes, policies and procedures, and ensure practitioners have the necessary skill sets. Some AMCs will have sufficient size and scale to build these capabilities, leveraging existing resources and supplementing, where necessary.
For example, the University of Pittsburgh Medical Center (UPMC) has built a sophisticated population health management system using its own health plan. Its approach includes Health Information Exchange (HIE) and Electronic Medical Record (EMR) capabilities, a patented analytics and care management workflow platform, and investments in clinical infrastructure and processes that support standardized practices and policies to drive quality and efficiency. UPMC and the publicly traded Advisory Board have created a for-profit subsidiary, Evolent, to enhance and commercialize UPMC’s care management and population health capabilities.
Identifying the Implications for Leadership
AMCs must adopt a new paradigm of care delivery that expands beyond the core specialty care services market and incorporates population health capabilities. Payers will be seeking high-quality, cost-effective options for beneficiaries. They will place a premium on organizations that can deliver efficient, cost-effective, high-quality patient care for a defined population. Leadership considerations include:
- An expectation that the health system of the future will be agile in identifying and segmenting populations by indicators, such as health status, socio-economic status and prevalent chronic conditions, as well as in defining care environments that meet the needs of each segment.
- The ability to define a population of beneficiaries and work to develop population health capabilities, either internally or in partnership with other organizations.
- The pursuit of a population health strategy that complements a focus on specialty care service development and improvement.
- Sophisticated IT systems, skilled data analysts and health services researchers and physicians, trained to understand data and translate it into better care at the population level.