Population Health Management

HealthLeaders Media Council members discuss how they have redesigned care delivery to support population health management in their organizations.

This article first appeared in the May 2017 issue of HealthLeaders magazine.

Renee Broadbent
Associate Vice President
Population Health and IT Strategy
Office of Information Systems and
Clinical Integration
UMass Memorial Health care
Worcester, Massachusetts

We have a designated entity within our organization called the Office of Clinical Integration, which functions as a population health management organization. Through that department, we have established value-based and population healthcare services, including care management.

We’ve also provided tools that create alerts when our patients are admitted to nearby hospitals, so we can better manage the patients and ensure their conditions are monitored and that they’re getting necessary care. In addition, we are evaluating our entire workflow so we can care-manage the self-insured population. We are in the process of moving toward a more comprehensive care management platform.

In addition, we have a variety of folks in our care management organization, including social workers and navigators who help our patients move through the system and access services.

The technology around population health is really interesting. While there were few vendors in the field a couple years ago, we’re almost saturated at this point. While the programs used to specialize in one specific kind of data, they cross-specialize more today, with care management programs getting into analytics, for example.

You need a good, robust care management tool that does a lot of things that allow your care managers to interact with it. Our organization is currently in the middle of transitioning to EPOCH, with plans to go live in October.

Jonathan Ringo, MD
Interim COO of Sinai Hospital
Vice President of Clinical Transformation
LifeBridge Health
Baltimore

The move to population health is a part of a larger series of changes we’ve made in the last few years to meet requirements regarding how healthcare is reimbursed in this country and in the state of Maryland, as well as to meet the changing needs of our community as we move from a

fee-for-service model to a value-based one.

We’ve made structural, organizational, and operational changes to meet those needs. We have significantly expanded our care management responsibilities both inside and outside of the hospital, looking at clinical pathways, registries, and chronic disease clinic programs. We have invested heavily in our IT infrastructure to support all of that, both from a clinical interoperability standpoint and from a predictive analytics standpoint. 

We’ve been working with our local providers to have them certified as a patient-centered medical home, as well as getting them certifications in chronic diseases such as diabetes. We have a lot of clinical programs specifically focused on high-utilization diseases such as congestive heart failure, COPD, asthma, and diabetes. We launched case management in our emergency rooms to prevent readmissions, and have trained our community health workers to do a lot of work around preventing admissions to the hospital.

Telemedicine is something that we’re also expanding, and we expect to see some big changes in the coming year as we endeavor toward the aim of providing the right care, in the right place, at the right time. 

James Bleicher, MD, SM
Regional President Physicians’ Organization and Ambulatory Services 
SSM Health St. Louis

When I look at how other organizations responded in your survey, I have to say, “Yes, this is us, and this is what we’re experiencing.” We have a care management team that is focused on our risk-based panels. We have some risk-based contacts, but they are by no means the majority—they only make up about 10% or 15% of our populations.

Some of the recent steps we’ve taken include special gaps-in-care processes, redesign of our primary care department, and running a patient-centered medical home, and we are working on critical programs by disease state, and also within each of the service lines, including cardiovascular, ortho, and oncology.

We’re redesigning our compensation model, and it’s set to go live in July. We’re adding quality, experience, and value-based measures to our physicians’ compensation. We recently hired 17 care managers and eight care coordinators. We’ve also brought on a new VP of population health.

Internally, we’ve been talking a lot about cost reduction, utilization, and improving quality of care. I think that a new emphasis on population health has helped us to realign our priorities back to where they should be for healthcare—the best care for every patient, and not just from a quality perspective, but from an efficiency perspective, too. It’s getting us back to evidence-based care. I’d say that this is a positive culture change.

Greg Weaver
Chief Operating Officer
Coteau des Prairies Hospital
Sisseton, South Dakota

On implementing population health in a rural setting: Our organization consists of four health clinics, three of which are rural health clinics, and one that is fee-for-service. What they all have in common is that all have historically been reactive. You come in when you’re sick, we fix you, you get a prescription, and you leave.

I’m a bit newer in this organization, having been here for about a year and a half. When I got here, there wasn’t any proactive healthcare going on, much less population health. I knew from previous jobs that electronic medical records could be helpful and contribute to proactive healthcare and population health. We [needed] to use our EMR to its fullest capabilities.

We switched over to an EMR that offers managed services and proactive population health management. Staff at our EMR vendor athenahealth calls our patients and reminds them of diabetes screening, colonoscopies, anything that will help patients to manage their health proactively.

On new roles in population health: We have also designed an in-house team with a case worker and a dietitian. They pull reports, look at charts, and call the patients to help monitor their health, such as those struggling with diabetes or obesity.

They manage the care of approximately 130 patients in our care who are at the greatest risk. They also work closely with patients who have more than one morbid condition.