Population Health Priorities

In our October 2015 Intelligence Report, healthcare leaders cited a variety of population health initiatives. HealthLeaders Media Council members discuss efforts that are important to their organization's population health management strategy.

This article first appeared in the April 2016 issue of HealthLeaders magazine.

Ann Oasan
President
UniNet Healthcare Network
CHI Health
Omaha, Nebraska

Physician and patient engagement are probably the most critical parts of population health. We've had care management in place in our primary care clinic for the past three to four years, and we've been very successful, but now we are focusing more on physician engagement.

Our use of care coordinators actually helps get physicians onboard for population health. When there is a patient who has a social need, physicians have a care coordinator who they can refer that patient to, and know they'll get the best care. The care coordinator has those resources at their fingertips, while a physician may need to do a lot of research to find some of these things.

We do receive claims data from many of our payers. Some of our payers are providing financial assistance to help manage those patients, which is helping pay for the infrastructure costs of our population health program. Several of our payers are recognizing that providers and payers need to work together, and they have been willing to sit down with us to design a program.

Julia Andrieni, MD
Vice President of Population Health and Primary Care, President and CEO of Physicians' Alliance for Quality
Houston Methodist
Houston

There are many important components to population health. Our research has yielded similar results to yours, although I might put the initiatives in a slightly different order, with an engaged primary care physician network at the very top, which would include both aligned and employed physicians. You need a pretty extensive geographic network for covered lives and population health, and aligned independent physicians outnumber employed physicians by a 2:1 or 3:1 ratio nationwide; you need them both to be engaged.

The second asset I'd say is key for us is a robust care management program. On that team, we have a clinical pharmacist, nurses, assistant nurses, certified diabetic educators, and more—it's a team-based approach that is utilized based on the health risk of the population, with more intensive management of the high-risk population we care for. The third-most important factor is participant engagement. To sustain outcomes and results, you need to engage participants in their own health. You can do all the work in the world for individualized care plans, match people to primary care networks, coordinate between the nursing care navigator and a primary care physician—but to sustain those results, I think you have to create an education and awareness for the patient.

M. Michelle Hood, FACHE
President and CEO
EMHS
Brewer, Maine

We have brought on several new roles due to population health initiatives. We had care coordinators previously, but they focused primarily on discharge planning and related issues. We have reorganized that function, and our population health team manages our care coordinators systemwide. We have brought on additional staff resources to do that.

Most of our care coordinators are nurses, but because of the high incidence of depression and other mental health issues that we encounter, we also have some clinical social workers and mental health professionals in the care coordinator role.

We've also hired pharmacologists who work with providers around medication management and we have one biostatistician, with plans to hire more.

We've been using home monitoring for some time, but we've increased the number of homes in our home monitoring program that are connected in real time to our care center. We've also used telemedicine effectively for a number of years, but we're seeing an expansion of that as well, particularly telepsychiatry.

We're looking to upgrade our data warehouse, and have hired a chief medical information officer and chief nursing information officer. They report to the chief medical officer, but oversee clinical analysts. We've had a variety of initiatives around data reliability and integrity.

John Holland
CEO
LHP Hospital Group
Plano, Texas

On setting priorities: The top three you've listed are definitely our top three, too, but I would put them in a slightly different order. I would say that physician engagement would be by far the top issue that we're working on across our different hospitals and markets. Second for us would probably be care management, and the third top issue would be patient engagement.

On getting clinicians onboard: Once you communicate and educate, clinicians understand why population health is necessary and what's in it for them. We've set up a clinical integration network, and we've worked hard to develop specific tactics around bundling and development of narrow network products with some of our insurance partners. We've also seen the need to integrate our work, whether it's in the outpatient physician setting, the hospital, or the ambulatory settings. On the physician side, I think it's important to foster strong communication and have great physician leaders who are advocating for their colleagues to sign off on population health and join us.

On patient engagement strategies: Most of our market has really been around what I call "the traditional blocking and tackling," which in a nutshell is making sure that our care strategies, the service we're giving the patient, and the interaction with any of our facilities or clinicians is a very pleasant experience. We've focused on ensuring the patients understand the care they're getting, and that they're engaged in their own care.