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Population Health: Slow but Steady Progress

Managing the health of diverse populations with often complex and disparate needs is no easy task. And though Population Health Management (PHM) may be a difficult challenge, the healthcare industry is starting to see early success stories.


There are a variety of definitions for population health management, which as a term, as supplanted “population health” within the healthcare community. The term population health is now used to describe the broader context of health including education, societal issues, etc. Here are a few example definitions of Population Health Management:

The iterative process of strategically and proactively managing clinical and financial opportunities to improve health outcomes and patient engagement, while also reducing costs. (Symphonycare)

Population Health Management is a collection of activities, not reimbursable in the fee-for-service model, but important in the care we deliver to our patients. (Partners Healthcare)

Population Health Management is the aggregation of patient data across multiple health information technology resources, the analysis of that data into a single, actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes. (Wellcentive)

Early Success Stories

Northwell Health – created an Office of Population Health Management: a centralized department within the health system that coordinates all population health efforts. Within the office: CareConnect, the health insurance plan and a care management group called Northwell Solutions coordinate services provided to those with chronic illness.

 St. Vincent Health System – saved $5.8M in 2015, giving credit to its participation in MissionPoint Health Partners ACO’s care management model. This provided the opportunity for groups of doctors, hospitals and other healthcare providers to share the financial benefit that comes from improving patient health while reducing costs.

Plant City Family Medical Specialists – says new CMS rules have been a gain to patients and the practice by using CareSync’s care coordination technology and 24/7 nursing services to help providers outsource their chronic care management initiatives.

PHM Implementation

To effectively implement population health, the initiatives must be central components of an organization’s overall strategy. One-time projects or task forces may help get started but won’t be effective by themselves. IT and data analytics are important so that clinicians have access to current information that enables them to identify and understand high-risk patients and share data about them with other clinicians. In some cases, telemedicine can help assure frequent contact: e.g. to verify compliance with prescription medication.

But many say that the biggest requirement for a successful implementation is a cultural or mindset change.  For example, rather than measuring the outcome of a procedure, the metric should be something like  “did the patient return to their previous level of health (or better)?” This requires leadership and training, coupled with a long-term focus and commitment.

Learning from Experience

While we know a lot about PHM implementation, there are still lessons to be learned from experience.

To date, PHM may be central to an organizations’ core strategies, yet many leaders and healthcare providers have only a vague understanding of how it will truly affect the way they deliver healthcare. For example, a patient’s activation level, or ability to self-manage health and health care, is linked to the risk of developing a chronic disease which uses expensive and avoidable health care services in the future. By stratifying populations by activation level, health care delivery systems are better able to identify and support patients with limited self-management skills, helping to improve outcomes and prevent unnecessary costs.

Successful population health management initiatives not only seek to improve coordination among providers and address social determinants of health and forge innovative partnerships, they also emphasize the importance of staff education and cultural evolution. In the long run, investing time and resources in each of these components will yield the best results, both for the community as well as providers.

Evolution of PHM

The growing momentum behind population health management represents a marked departure from traditional healthcare. PHM metrics are focused on prevention and long-term health improvement, the patient’s ability to return to an active lifestyle, rejoin the workforce, and maintain a high quality of life.

Most of a PHM strategy’s success depends on clinicians and administrators who are on the front lines of delivering care. With support from leadership, if they have the tools to understand the population being served from the patient’s perspective and turn that understanding into a customized action plan for each individual, real progress is highly likely.

Of course, more sophisticated technologies and tools are on the horizon. Bat the end of the day, PHM success happens one patient at a time.


Source(s): Dowling, Michael, “Michael Dowling: How to Make Population Health a Robust Strategy — Not a One-Off Project,” Becker’s Hospital Review, September 8, 2016; Monegain, Bernie, “St. Vincent’s Saves $5.8 Million with ACO, Population Health Programs,” Medical Practice Insider, July 18, 2016; Miliard, Mike, “Practice Puts Chronic Care Management Tools To Work In Population Health Strategy,” Medical Practice Insider, July 18, 2016; Ananth, Sita, “Tackling Contradictions of Population Health, and Five Key Success Factors,” H&HN Magazine, September 1, 2016; Jain, Anil, “The 5 Areas to Target in Improving Population Health Management,” H&HN Magazine, September 1, 2016; Hibbard, Judith; Greene, Jessica; Sacks, Rebecca; Overton, Valerie; Parrotta, Carmen, “Improving Population Health Management Strategies: Identifying Patients Who Are More Likely to Be Users of Avoidable Costly Care and Those More Likely to Develop a New Chronic Disease,” The Commonwealth Fund, August 23, 2016; “Q&A: New York-Presbyterian CEO On Population Health, Expanding His System,” Modern Healthcare, August 13, 2016