Monthly Archives: August 2015

The 3 P’s of Population Health

Post by Brad Miller

Vice-President of Clinical Solutions, Caradigm

When most people think of the term “Population Health”, visions of ACOs dance in their heads. ACOs are a provider group that pulls together patients and contracts at a fixed rate per patient over a given timeframe while either maintaining or increasing quality of care, with savings typically accruing to all parties. An academic definition of pop health is: “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” While that definition may be accurate, I find it a bit nebulous, and would like to suggest the 3 Ps of pop health to simplify the definition and conversation: the Population, the Patient and the Practice. The 3 P’s provides a specific framework under which to have practical conversations around population health.

The Population

The population is the collective patient cohort that a provider has contracted with a paying entity to provide healthcare for a fixed price. In the case of CMS’s Medicare Shared Savings Program, providers receive payments based upon traditional CMS fee for service schedules, but are then incentivized to provide higher quality care through ACO33 measures, and have their populations risk-adjusted using the CMS-HCC methodology. Providers must now determine efficient and effective ways to deploy their limited care resources in order to impact clinical outcomes and overall population savings. In the case of private ACOs or health systems directly contracting with self-insured employers, the population is defined by that contract. To make this more complex, a provider’s overall population health approach may be comprised of many contracts – each with its own specific population and contract behind the care. This population complexity adds an additional element of chaos in an already chaotic system.

The Patient

The paradox of population health is that in order to “move the needle” on a population, a provider must focus on the specific needs and use cases of each and every patient who is part of the population. While I will dive into the specifics and caveats of how to define an individual’s care in later posts, for now I want to establish that “the patient” is a critical component of any ACO. Each patient of a defined population has their own health issues and specific personal needs. For example, one member of a population may be a relatively healthy 68 year old woman in good shape, but has moderately high cholesterol. Her personal issues and barriers to care will be completely different than a 74 year old, wheelchair-bound diabetic with heart failure. The critical component to improving the value of healthcare and drive quality measures for a population is understanding how we can make the individual patient respond to care and meet their own needs. Delivering personalized care for each patient is critical for the long-term success of any population health model.

The Practice

Here lays what I find to be the most important of the 3 Ps of pop health – practice. Yes, it’s all about the people – both on a macro (the population) and micro (the patient) side of things, but population health itself is a practice, much like medicine, and yet we do not treat it as such. Best practices and models are unique to the provider, the patient base and payers involved. What has worked at one provider may not work at another. More direct, what has worked for a rural, integrated care network will not work at an academic medical center, will not work at a large urban public hospital system. While the basics may be similar the practice and execution of the basic models will be very different However, I would argue that the learning, best practices and business models from these efforts can serve as a starting foundation for a population health effort.

At the surface, this seems to be self-evident, but I have seen providers establish fairly rigid care and financial models and too often not create a governance or technical infrastructure to embrace the practice of population health. From my time working with ONC’s Beacon Communities and CMS’s Innovation program, most of the reasons programs were not successful can be traced back to overly ambitious and complex beginnings that were rigid in approach. Successful programs were more modest in size, focused on specific measures and outcomes, and allowed for the learning and iteration on successes and small failures. From those more modest beginnings the successful programs expanded their capabilities as they learned how to assess risk, create effective population cohorts and to deploy personnel to meet the individualistic challenges faced by their populations. Most of the successful organizations were able to iterate and iterate often, which allowed providers to hone the practice of managing large, diverse populations. All of these challenges are unique to each population health effort – and may actually be different on a contract-by-contract basis for each provider. The bottom line is that population health is a practice – one that can take years to make robust and to perfect.

I will tackle each one of these 3 Ps in upcoming posts. For now, the 3 Ps act as a basic framework for conversations around the path to pop health success.

Engaging High Risk Patients through Care Management (Part 2)

Post by Vicki Harter, BA, RRT

Vice President, Care Transformation

In part one of this post on engaging high-risk patients through care management, I discussed how different patient segments require different levels of care management relationships and tools. For the highest risk patients, a patient engagement strategy is centered on high intensity care management. Next, let’s look at how technology can help care management have a greater impact on outcomes for the highest risk segment.

Coordinating Care Across a Multi-Disciplinary Team

The care for a high risk patient can involve a large team including multiple specialists, pharmacists, care managers, office assistants, community health organizations and family members or friends. Coordinating activities among a diverse team requires shared access to a longitudinal patient record that gives a comprehensive “360 degree view” of the patient. The 360 degree view includes information such as:

  • Claims data (e.g. services obtained, medications, etc)
  • Dynamic care plans
  • Lab results
  • Medications
  • Patient outreach information
  • Patient supplied information (biometrics, logs/journals, preferences, etc.)
  • Predictive analytics such as a readmissions risk score, clinical risk, forecasted cost, etc.
  • Barriers to care
  • Gaps in care/quality measures that need to be closed
  • Important non-clinical information (e.g. patient motivation, family support team members, life events such as a recently deceased spouse, and other social factors)

With this enriched view of the patient, care team members across the continuum can work more efficiently together closing gaps in knowledge and communication while operating at the top of their license. This can result in reduced redundancy in assessments, surveys and tests. Today, enterprise population health technology can bring together and make available all of this information in a shared workspace even if the information is stored in disparate IT systems.

Incorporating a patient-centered approach

A deeper understanding of patients helps drive a patient-centered approach, which is critical for patient engagement. For example, if a patient is motivated to achieve a certain goal such as travel to her daughter’s wedding, then every member of the care team can reinforce her motivation and encourage the patient and engage them in the plan of care. If every care team member has access to all patient information, then patients won’t have to repeat the same information to different care team members and patients begin to sense coordination among providers. If there is a family member, friend or community organization that plays a key role in the patient receiving care, then that critical piece of info will be incorporated into the assigning of tasks. The end result is a personalized plan of care. If patients see that the entire team “knows” them, it improves the overall patient experience, builds trust and can improve engagement.

Optimizing time with patients

Care managers are often challenged by a high volume of daily manual tasks. For example, in order to assess a patient and complete a care plan, care managers must track down and synthesize information from multiple systems and offline sources. With a full case load, efficiency is a challenge that ultimately impacts the amount of time care managers can spend focused on patients. Technology can help care managers spend more time with patients by automating time-consuming tasks. For example:

  • Care plans, task lists and interventions can be automatically generated and updated from assessment responses
  • Complete medication histories can display order history and fill history to enable faster review and support compliance review
  • Patient workloads or specific tasks can be reassigned to other care managers or support staff, assuring “top of license” activity
  • High risk patients can be tracked across the continuum through event-based alerts (e.g. admissions, discharges or blue tooth device alerts).

To summarize the main takeaway from both posts, patient engagement and care management strategies are closely linked and should be tailored by segment. As part of population health initiatives where the focus is often on high-risk patients, patient engagement strategies should be on a one-to-one basis, and linked to relationship building through high-intensity care management. New population health technology has emerged to help coordinate care for the highest risk patients. As more providers make the shift to value-based care and seek efficiencies to help them scale programs, I believe that technology will play a central role in helping the highest risk patients. If you’d like to discuss your care management strategies in more detail then send us a note here.

Engaging High Risk Patients through Care Management (Part 1)

Post by Vicki Harter, BA, RRT

Vice President, Care Transformation

One of the most challenging issues in healthcare today involves “patient engagement”. It is defined by the Center for Advancing Health as “Actions individuals must take to obtain the greatest benefit from the health care services available to them”. The importance of patient engagement is undeniable. Patients active in the participation of their own care have a greater likelihood of achieving successful outcomes. How providers should approach patient engagement for different patient segments is still an evolving science. Patient engagement requires different levels of care management relationships and tools for different segments. In this two-part blog post, I am going to focus on the highest risk segment, and will address lower risk segments at another time.

Population health management is a large undertaking, requiring a variety of approaches to assure broad impact. The figure below shows an example of patient segmentation along with the types of care management relationships and tools appropriate for each segment. At the top of the pyramid is the highest 5 percent in terms of risk. In the middle are the 30 percent of patients with rising risk. The base of the pyramid is the 65 percent identified as having low risk. Let’s examine the segments more closely to see how patient engagement and care management strategies can vary between the segments.

CM Pyramid


High Risk

The top 5 percent of patients require high-intensity, 1 to 1 care management involving a multi-disciplinary team. Patients may have comorbidities that require more complex coordination across the continuum of care. Due to the high clinical risk for this group of patients, a care manager needs to play a lead role within the care team, guiding patients to take the actions needed to obtain the greatest benefit from the health care services available to them. Therefore, a patient engagement strategy for high-risk patients is really centered on high-intensity care management providing direction to the appropriate level of care and education about symptom monitoring and action plans.

Rising Risk

In general, the rising risk segment requires moderate intensity care management services, referred to as condition management in the diagram. These patients can pose an escalation risk if unmanaged, so the emphasis is on providing a consistent set of evidence-based care or education about self-management of a newly diagnosed condition. Patient engagement for medium risk patients is often a combination of consistent patient outreach and communication along with tools to encourage self-management. Within this group, there can be a subset of patients identified as “movers”, patients whose level of clinical risk is predicted to increase over the next 12 months. Higher intensity care management can be appropriate for “movers” in order to proactively address their conditions before they become more acute.

Low Risk

The low risk segment is the largest group, nearly two-thirds of the population. The focus for this segment is on preventive health and wellness to provide age and gender appropriate recommendations for care. Wellness tools including patient education and coaching may center around lifestyle choices and illness prevention based on health risk assessment data. Due to the size of this segment, low-risk patients must take on more of the responsibility for self-care. They are the ideal segment to benefit from patient engagement and outreach tools such as an interactive portal and patient reminders.

In the second part of this post that will be published next week, I will go deeper into technology designed to achieve effective high-intensity care management.