Has population health finally arrived? Yes and no. Population Health Management (PHM), like artificial intelligence and precision medicine, is a massive, investment-intensive work-in-progress—and very auspicious in that it has the potential to forever change the way we deliver (and receive) care.
However, while we’ve seen progress in some areas of PHM, its scale and complexity has led to false starts in others, and we’re lacking a holistic approach to the overall job to be done because there is no one right way.
If we are truly going to achieve the quadruple aim for the next generation and move from mere “hype” to actionable workflow that lifts the burden from physicians, care teams, and patients, we need a cultural and behavioral shift across the industry. We need to deal with some of the biggest barriers to PHM—the disengaged and unempowered patient, the burned-out care teams, and the missing connective tissue from providers and care settings that could all start to help the industry rise above hype. Beyond this foundation, we need to focus not just on the riskiest 5-10 percent of patients who are sick and most costly now, but embrace data and technology that lean into monitoring and engaging the other 90-95 percent so we can minimize where it might hurt later. The tenets of population health (e.g. care management) need to be broadly applied across all patients regardless of payer arrangement. The question is: How do we get there in a scalable, efficient way?
Well, for starters, find a technology platform that can aggregate large quantities of data.
The lifeblood of any population health program is data that can be aggregated from any source, centralized, and shared with the full care team in an actionable way. You want to have full visibility into the patient journey through your healthcare ecosystem to avoid duplicative efforts, and the capability to surface actionable insights that in turn help target where to direct precious resources. You need a partner with expertise in aggregation, workflows, and, most importantly, a partner open to providing access to population health tools to those outside your network in order to drive outcomes in a patient-centric way.
It’s also important to act on data: Equip patients to co-manage care alongside providers.
There is arguably no greater, more important goal than enabling patients to take part in their own care. Yet most organizations have no systematic approach in place to effectively orchestrate or engage patients at scale. With 80 percent of healthcare decision-making happening outside the clinical setting, ensuring touchpoints with patients between visits is critical. Consider investing in digital solutions like a remote care platform that gives patients and providers the power to connect anytime, or a self-management app, which enables patients to track care plans and self-report to care teams on a mobile device.
Think in terms of a global network of care: Care is a continuum, not a singularity.
Care management is evolving beyond single, insular, fixed settings—like hospitals—and becoming a global network of care that includes all care team resources. At this point, the free flow of patient information across settings (and the technology that enables it) should be tablestakes. Mission Health Partners in North Carolina, one of the largest ACOs in the country, has experienced this first hand. Mission is part of a national network that is built on a single-instance platform, coordinating care and aggregating data across Mission’s 30+ EMRs, care coordinators, pharmacy technicians, social workers, local hospitals, and nearly 300 primary care physicians and 800+ specialists within its ACO network. This has allowed Mission to achieve wraparound care with an interpersonal approach and millions in MSSP savings.
Teamwork makes the dream work: Gain buy-in from physicians and align care teams around objectives, processes, and a data-enabled vision.
With physician burnout at an all-time high, lack of physician engagement can rapidly derail population health initiatives and cost-saving efforts. Once an organization embraces a common technology platform, adjusts to a unified clinical workflow, and agrees on evidence-based protocols, the administrative burden caused by duplicative efforts is lessened and physicians are freed to deliver quality care. The right partner will offer insight into workflows, provide concrete feedback that highlights excellent provider performance, flag workflow issues, and identify service inefficiencies in quality management, coding, and care collaboration.
And to sum it all up, learn from the past and be agile.
Results matter. If your population health program can’t draw on insights and best practices from previous learnings—from your organization as well as others—to predict future success and close gaps in care, demand that it does. If your partner can’t coach you to better performance, then look for one that can. Stop trying to make a solution fit your organization; instead, partner with those that align with your organization’s desired outcomes and are able to provide the tools and resources you need to be successful.
It can be difficult to establish and support the free flow of patient information across settings, particularly when 50 percent or more of care is considered “out-of-network.” No organization can be an island, nor can your partners be stingy about access to data. Healthcare systems must realize that even though there’s stiff competition in market, they must work together to be successful in their population health goals.
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