Population health management is an important task in healthcare, and one that will require highly coordinated care, close relationships among providers and advanced technology infrastructure. But before any of that can happen, hospitals and health systems need to change their mindset about their purpose and role in the community.
Redefining roles
"Hospitals need to stop thinking of themselves as hospitals or facilities, and think of themselves as part of the continuum of care," says Jonathan Niloff, MD, vice president and executive medical director of population health at McKesson. "Hospitals need to start thinking about how they are going to reorient themselves." For example, instead of trying to attract as many people to inpatient care as possible, which is a strategy for a volume-based payment model, hospitals should be focused on getting patients to the most appropriate setting of care, whether that be inpatient, outpatient or the home.
Hospitals are not the only ones who need to change their attitude. Individual practices and physicians also need to adopt a broader perspective about how they treat patients. Rather than only focusing on single episodes of care at single points in time, physician practices need to think about populations and the health of individuals over their lifespan, according to Dr. Niloff. "Individual providers and their teams in the practices need to stop practicing transactional medicine and start focusing more on a population health approach," Dr. Niloff says.
In addition, other clinicians within hospitals and practices, such as nurses and care coordinators, may need to redefine their roles so each individual can practice at the highest level of his or her training, according to Dr. Niloff. For example, care coordinators can follow-up with patients over the phone after an ED or hospital visit, remind patients of preventive screenings and monitor chronic illnesses, while physicians can provide direct care to the sickest patients.
Coordinating care as a team
As part of a population health strategy, all providers need to take a more team-based approach to care. Physicians and hospitals will need to work more closely together, especially during transitions of care. When a patient is discharged from the emergency department or hospital, patients' primary care physicians and other relevant ambulatory providers need to know. Hospitals should share patients' discharge information with the outpatient physicians so these physicians can provide the appropriate follow-up care.
Relationship building
To ensure patients are cared for throughout the continuum of care, hospitals, physicians and other providers need to build relationships that will help them communicate patient-related information and establish care protocols. Hospitals, physicians and other ambulatory providers should clearly delineate responsibilities so patients don't fall through the cracks. For example, if a patient was in the hospital for a simple surgical procedure, the surgical unit may be responsible for following up with the patient. If a patient was in the hospital for a chronic illness, however, the primary care physician or relevant ambulatory specialist may be the most appropriate person to conduct follow-up, according to Dr. Niloff.
As part of building relationships, hospitals should collaborate with physicians in developing their population health programs and explain how together they can improve care for patients across the continuum. Engaging and educating physicians about the hospital's motives for partnering helps build trust and a culture of transparency.
Hospitals can also establish incentives for physicians that align with population health goals. Sometimes simply sharing data with physicians in a transparent way can be incentive enough to change behavior, according to Dr. Niloff. Showing peer comparisons can spark healthy competition and motivate physicians to focus more on prevention and wellness.
IT infrastructure
An important component of population health efforts is IT infrastructure that supports information-sharing and care coordination. Interoperable systems can ensure all providers have the same information about patients, allowing them to make more informed decisions. "Building the right communications and data-sharing infrastructure enables all of the community-based physicians the health system has established relationships with to be in a position empowered with the right data to deliver optimal care," Dr. Niloff says.
In addition to using IT systems to share patient data, hospitals and physicians can use these systems to establish patient registries and predictive models. These models can help identify patients in need of ongoing monitoring, such as those with chronic illnesses, and those at risk for developing illnesses or diseases, such as smokers. Having the right technology can help providers optimize their resources and improve quality by targeting the patients who most need medical services.