Key Components to Fortifying Population Health

By applying data, testing new approaches, and establishing community partnerships, you can bolster patient outcomes.

This article first appeared in the March/April 2018 issue of HealthLeaders magazine.

The dilemma of keeping patients healthy beyond the hospital walls often means that healthcare leaders must shift their organizations into a vulnerable and uncomfortable space that involves taking risk, partnering with outside organizations, experimenting with new ideas, and being willing to fail in order to learn.

Fifty healthcare executives in executive, clinical, and information technology arenas gathered in Colorado Springs, Colorado, last summer at the HealthLeaders Media Population Health Exchange to discuss their approaches for delivering comprehensive care to diverse populations.

Ideas that surfaced during the discussion to drive quality, reduce cost, and improve the overall health of the community included the following:

Base measurement on a source of truth

Achieving measurable improvement requires aligning disparate sectors within a healthcare system and with external partners via data.

"[Finding common ground] depends on getting agreement in terms of my data, our data, and their data—and what we're viewing as a source of truth," says Mac McClurkan, chief strategy officer at Oaklawn Hospital, a regional healthcare organization in Marshall, Michigan. "What is the data telling us, and how do we make those insights actionable?"

Determining and prioritizing the metrics by which an organization measures itself is how Allegheny Health Network (AHN), an integrated healthcare system based in Pittsburgh enhances patient care, such as lowering readmission rates.

"We had a readmissions summit, in which we brought key stakeholders from across our network—including payers—to the table, presented our data, and created groups to work on [improvement] projects related to readmissions," says Sam Reynolds, MD, chief quality officer. "But you need to have a metric (e.g., readmission rate) by which you can measure your success. A cross-cutting metric is needed to gain general consensus across all sites of care."

Through its homecare and skilled nursing facility (SNF) entities, Charlotte, North Carolina–based Carolinas HealthCare System, an integrated network in North and South Carolina, initiated a postacute collaborative with data submission requirements for its organization as well as community partners.

"Finding common ground depends on getting agreement in terms of my data, our data, and their data—and what we're viewing as a source of truth."

Mac McClurkan, chief strategy officer at Oaklawn Hospital, Marshall, Michigan

"We're moving all of our entities to the same care management platform in rehab, behavioral health, and the postacute space, so everyone can communicate across those systems," says Ruth Krystopolski, senior vice president of population health.

Establish beneficial partnerships with community organizations

A healthcare system can only go so far with population health endeavors without help from social service and community organizations.

Sutter Health, a nonprofit network of hospitals and physicians, serving more than 100 communities in Northern California, partners with the City of Sacramento to deliver first aid and referrals to social services for the homeless.

"Our nurses are out in the community providing care—supplying people with such things as needles and diabetic kits, and connecting them with free community resources," says Sameer Badlani, MD, vice president and chief health information officer for Sutter Health.

 Houston Methodist, which includes a leading academic medical center and seven community hospitals serving the Greater Houston area, awards grants to federally qualified health centers and other community partners to collaborate on building healthy communities.

"We've also seen results in our collaboration with Meals on Wheels, in which drivers ask transitions-in-care questions of recipients and relay the information to our nursing care navigator team, so we're on top of the curve," says Julia Andrieni, MD, vice president, population health and primary care, Houston Methodist; and president and CEO, Houston Methodist Physicians' Alliance for Quality. "As a result, we've learned about medication errors, food insecurity, and other social determinants."

Understand that true innovation is risky, experimental, and can be messy and painful—but leads to great rewards

With change being a constant in healthcare, nurturing and introducing innovation into the workflow can meet resistance among those weary and wary of the next new idea. Yet leaders know that innovation equals fiscal survival, and it's imperative to create a risk-tolerant environment.

"You need to have a metric by which you can measure your success. A cross-cutting metric is needed to gain general consensus across all sites of care."

Sam Reynolds, MD, chief quality officer, Allegheny Health Network, Pittsburgh

"If the leadership is not willing to force the business portion of the organization to adapt to the various innovations, it won't move forward," says David Battinelli, MD, chief medical officer for Northwell Health in New York state. Northwell Health is a nonprofit healthcare network with 22 hospitals.

Changing risk-tolerance of an organization isn't automatic, points out David Stowers, RN, PhD, vice president, enterprise care management, at four-hospital Covenant Health
Partners in Lubbock, Texas.

"Everybody likes their own comfortable way of doing things," says Stowers. "So, the first thing we did at Covenant was to set up a pilot for four different processes, each with relatively low risk, understanding that some may fail. Some did, and others—like care navigators in primary care—did not. But the medical staff at Covenant and the administration could see that by putting in small processes, we were impacting little things, and that would grow to bigger things."

Read the HealthLeaders Media Exchange Insights Reports about population health at: Unifying the Care Continuum and Innovation: 5 Reasons Why Yours Aren't Working

The next Population Health Exchange event will occur on July 11–13, 2018, in Coeur d'Alene Resort, Coeur d'Alene, Idaho.

Julie Auton is the leadership programs editor for HealthLeaders Media.