Population health management is a critical component of value-based care. And while the oft-used term's definition varies across organizations, wellness and prevention are always at the foundation.
"Population health management requires both planned and unplanned care," Eric Beck, DO, president and CEO of Evolution Health, said at Becker's Hospital Review's 7th Annual Meeting in Chicago. "These shouldn't be two disconnected strategies, but interwoven on a path to wellness."
Dallas-based Evolution Health, a subsidiary of Envision Healthcare, is a provider of mobile integrated healthcare, specializing in the care and management of patients in the home and alternate settings. The company helps its hospital partners connect to and enhance relationships with organizations and existing community assets to best support patients at the highest risk of hospital admissions.
The Evolution Health model, which uses a medical command center, specializes in triaging, resource matching and connecting generally disparate elements of care. Its medical command center staff gathers information from patients to make specific decisions about the kinds of resources they need — such as social workers or mental health providers — to keep them healthy and out of the hospital.
Here are four key considerations for building up population health management efforts, according to Dr. Beck.
1. Education. Adopting a population health management framework requires a significant amount of education for caretakers both inside and outside the hospital. Whether a hospital chooses to use a classroom-based or online education model, the most important aspect to relay to learners is the intentionality and value of connecting the emergency room, post-acute providers and technology, and how interweaving these can improve outcomes.
2. Integration. Coordinating care between providers in the inpatient setting — particularly the ER — the outpatient setting, as well as in the community is integral to effective population health management. However, bringing these disparate providers together and teaching them how to communicate and coordinate care takes time.
"We spent a year learning how to get a hospitalist, a community paramedic and home care nurse to play as a team," said Dr. Beck. "This is not a group of clinicians that typically interacted before. We had to identify core competencies for each in a population health model — not so much related to clinical activity, but in handoffs and coordinating care."
3. Predict population risk. Using data on readmissions and vulnerable patient populations to identify where to target resources can have a significant effect on outcomes. Wherever there is high risk for utilization, there is a potential to improve the return on investment, according to Dr. Beck.
4. Engage patients. "Patient activation builds the strongest bridge between the clinical business and consumer-oriented tools," said Dr. Beck, though he noted patients fall across a wide spectrum when it comes to their own engagement. "On one end of the spectrum, they believe their healthcare is someone else's problem. On the other, they are highly engaged and good consumers of healthcare services." Interactions should be tailored to most effectively communicate with both types of consumers, according to Dr. Beck.