Is Your System Ready for Population Health Management? By Dale J. Block, MD, CPE

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1 Population Health Is Your System Ready for Population Health Management? By Dale J. Block, MD, CPE In this article Health care organizations will need to migrate to population health management sooner rather than later in response to statutory and regulatory pressures coming from the federal government. In 2011, the Health Care Advisory Board s Care Transformation Center published Three Key Elements for Successful Population Health Management. This research briefing began by identifying some thought-provoking questions for health system leaders planning and preparing for population health management: 1. What businesses should we be in? 2. Who will our partners be? 3. What is our role in the communities that we serve? These questions arise because of accelerating environmental forces that are causing major changes in the delivery of health care services in the United States today. These forces include: Enrollment in Medicare is climbing exponentially as the U.S. population ages. The big data revolution is exploding with increasing IT infrastructure and data analytic requirements along the continuum of care. The incidence of chronic, preventable disease is reaching epidemic proportions. The increasing statutory and regulatory requirements are coming from the Affordable Care Act. Because of these forces, health care systems and providers are facing a new business model focused on providing comprehensive health care services while managing the risk for the costs of care to their patients. Research discussed in the report suggests that all health care organizations must create a transitional path to population health management sooner rather than later. The report outlines several critical elements to this transformation including: Developing clinical decision-making. Establishing a primary care-led clinical workforce. Initiating patient engagement and community integration with local constituencies. Developing information-powered clinical decisionmaking requires the use of robust patient data sets acquired along the continuum of care that support proactive, preventive and comprehensive medical care, operates within an integrated data network, and positions a physician leader to merge complex data analytics with clinical care processes. Establishing a primary care-led clinical workforce elevates the primary care physician to what amounts to CEO of the patient care team and mobilizes a community workforce to extend the care team reach to where people live and work. Initiating patient engagement and community integration with health system s local constituencies will map health care services to population need. The effort must overcome nonclinical barriers to maximize health outcomes and safety, integrate patient values into personalized individual care plans and use community stakeholders to connect people with high-value health care resources. Developing clinical decision-making The information health care ecosystem is rapidly changing. Population health management requires health 20 PEJ MARCH APRIL/2014

2 care organizations to focus on identifying and using patient data and information collected along the continuum of care that will support evidence-based clinical decision-making. Today, many health systems have begun the arduous task of building toward data integration based on realtime clinical information from multiple patient access points of care. This will provide a competitive advantage for early adopting health systems and offset the high opportunity cost of developing their IT infrastructure to meet these new demands. Robust patient data sets collected along the continuum of care will connect individual patients to their primary care physicians in ways that will allow for predictive modeling of future health care issues. Adding an individual s complete genome (now available commercially at a very reasonable cost), means personalized health care delivery will no longer be a dream, but a reality. A customized diagnostic profile, including a physical examination and detailed biomarker analysis, will individualize care plans for not only the present, but also the future. Realtime ongoing biological screening and self-management reinforce the individualized care plan. Primary care physicians will be able to have an accurate assessment of an individual s health status and intervene before problems occur, thereby delivering the most appropriate care at a lower opportunity cost. As data becomes universal, health care organizations will differentiate themselves from each other by what they do with that data. Designing and implementing integrated data networks will leverage patient information sharing across platforms within an organization and across independent providers. Health information exchanges are increasing rapidly along the IT landscape. Individual organizations will no longer have proprietary ownership Health care organizations will need to acknowledge the role of community health care workers in the delivery of non-clinical care services. of patient information. Thus, ongoing access to and analysis of patient health information regardless of its place of origin is key to providing proactive, preventive and comprehensive care. This integrated IT approach to patient information leads an organization along the continuum of developing a culture of value-based health care. Challenges for every health care organization are to leverage and apply complex data analytics for clinical information collected along the continuum of care. System leadership will need to identify a physician champion with the appropriate knowledge and credibility to lead this effort. CIOs and CMIOs will continue to focus on building, refining and maintaining the IT infrastructure for the system. The chief of population health management, the CPHM, has critical operational responsibilities including mining clinical and operational data, distilling best clinical practices across their organization and creating templates for information-driven care plans for patients. Businesses and the community at large are demanding proven clinical programs that have the greatest measurable impact on quality, safety and outcomes while simultaneously lowering the cost of care. This is the value proposition for health systems as they design and develop their Accountable Care Organizations (ACOs) for a competitive edge in their individual marketplace. Establishing a primary care-led clinical workforce According to the Health Care Advisory Board s report, advances in information driven health care delivery will have a profound impact on the current and future clinical workforce. Leveraging integrated clinical information gathered and organized through complex analytical data systems will greatly depend on the health care providers connecting directly with patients along the continuum of care. Advances in technology will also allow health care providers to extend ACPE.ORG 21

3 Population health managers need to build connections across the entire continuum of care. the reach of the clinical workforce deep within the communities they serve, managing larger virtual clinical teams and panels of patients to help improve overall population health. There is great concern by many in health care that the critical issue for primary care will be a shortage of physicians in the years to come as older physicians leave the workforce and younger physicians migrate toward specialty care. Filling this widening gap will require a significant paradigm shift for all health care organizations. Health care systems will need to build comprehensive primary care teams, with the primary care physician working as the CEO to manage care across a range of providers including advanced practitioners, nurses, social workers, pharmacists, nutritionists and others. The priority will be to enable top-oflicense practice for all professionals in the care team. The CEO physician will be the team and operational manager making leadership decisions for the group. This individual must be service-oriented with strong interpersonal skills. Additional skills may include financial, operational and clinical information capabilities. Finally, traditional business competencies such as leadership, strategy and delegation of care services are critical elements for success. Care team members will need to posses the following characteristics: Effective communication skills. Teamwork ethics that promote top-of-license practice. Strong critical thinking skills. Comprehensive, longitudinal and proactive patient care focus. The ability to coordinate and manage nonclinical personnel working within the community. Health care systems will need to promote physician-led, professionally managed care teams that are scalable across the continuum of care within the system. This ultimately requires that primary care physicians will need extensive training in team management. Additional consideration will be to align incentives for team care to population health management goals. Finally, the long-awaited changes in compensation methodology for team care will drive quality measures in and productivity measures out. Of great interest to many will be the mobilization of a community workforce to extend the care team reach. These individuals will be nonclinical workers (e.g., community health workers) who can help patients navigate the health care system and peers such as diabetic patients who can provide ongoing health coaching and support to others that share chronic disease states. Community health workers have been involved along the periphery of health care delivery for some time. These individuals, living and working in their communities, become trusted resources by bridging language and cultural barriers between patients and the health care delivery system. As care teams become implemented, health care organizations will need to acknowledge the role of community health care workers in the delivery of nonclinical care services. The reach of health workers into the community will bring individuals requiring health care services into the most appropriate access points for care. This model fits into the proactive, preventive and comprehensive model of team care resulting in systems meeting their value-based goals (i.e., fewer inappropriate emergency room visits, hospital admissions and readmissions). Initiating patient engagement The last critical element of population health management shifts the focus for health systems outward toward the patients and the communities in which they serve. This change in focus is new territory for many health care systems. The Health Care Advisory Board s report provides insight for health systems for managing this shift. According to the report, the challenge for health systems today in becoming a patient-centered enterprise is accepting that people, in general, do not want to be considered patients. Accepting this premise places health care providers outside of the sphere of most people s day to-day activities. In order for health systems to migrate toward value-based care, it is imperative for the system to integrate into people s daily lives. Population health managers need to build connections across the entire continuum of care, both traditional and nontraditional. Matching and mapping health care services are critical success factors in meeting community health needs. Reaching out to other organizations delivering health and social services to the community builds a seamless continuum of patient centered care. This collaboration is fostered through open communication and allows for a significant reduction 22 PEJ MARCH APRIL/2014

4 When the road is ever-shifting, you need a partner that can help you stay ahead of the curve. That s where we come in. At McKesson, we re at our best when we work together. So we work closely with your team and align with your strategies and goals. Because whether you re managing populations, forming provider networks, or working to stay on top of regulatory change, McKesson is here to provide the solutions you want, and the partnership you need. Interested in hearing more? Sign up for a Better Health 2020 Expert Chat with a McKesson thought leader at HIMSS. To schedule in advance, visit McKesson.com/himss14, or come see us at the following booths: #1365 and #1665, HIMSS Hall A McKesson Corporation. All rights reserved. ACPE.ORG 23

5 in duplication of community offerings. Strengthening options across the continuum of care can simultaneously improve utilization patterns and better serve the community needs. Overcoming nonclinical barriers to maximize health outcomes is the greatest barrier to improving individual health. According to the report, social barriers (e.g., age, gender, impairment) and financial barriers, not clinical issues, lead to poorer health care outcomes for those who are chronically ill. Transportation problems, medication use, adherence to medical treatment and other public health issues such as adequate shelter, nutrition, sanitation, etc., require the assistance of nonclinical community resource specialists to work with care teams to influence health outcomes. This approach allows everyone on the clinical team to work at the top-oflicense while having important nonclinical issues addressed and resolved. Acknowledging and addressing nonclinical challenges outside of normal primary care structure improves clinical outcomes, especially for the highest-risk patients. Often overlooked by the care team is considering integrating patient s values into the care plan. To be truly patient-centered, health systems must acknowledge that patients are people first. This should factor into care planning especially for those with end-of-life issues. By discussing personal goals, clinical care can be delivered more efficiently and effectively by using less costly venues while still providing maximum levels of health care services such as hospice care based on the wishes of the patient and family. The critical success factor is initiating the proactive discussion before admission to the intensive care unit. Health systems biggest challenges will be accepting the responsibilities of improving the health of the community. Population health management requires identifying people who are at risk for disease and bringing them into the system. This allows for managing underlying health problems before they become acute, requiring higher costs of care. To do this, partnerships with other organizations in the community are crucial. Credibility, transparency and accountability are key to connecting patients with high-value resources in health care systems. By embracing key elements for successful population health management, health systems will get to value-based care more efficiently and effectively. Identifying a key physician leader and allowing this respected clinician to distill the principles and practices of population health management throughout their organization will promote acceptance of this new model more quickly by all who will be delivering health care services. With the Affordable Care Act forcing implementation of several statutory provisions beginning this year, failure is not an option for most health care organizations. Careful and ongoing strategic planning is required because of the rapidly changing landscape in health care delivery for the next few years to come. Dale J. Block, MD, CPE, is a full-time practicing family physician with Premier Family Care of Mason in Mason, OH. 24 PEJ MARCH APRIL/2014

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