Population Health can be defined as the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals. Population health management is the aggregation of patient data across multiple health information technology resources. To talk about Population Health is to talk about Population Health Management. A proper analysis of population management aids the understanding of where a health system is and aids in the adoption of better and improved practice systems to enable health practitioners to figure out what is needed. An effective and efficient population health management program requires fundamental changes to the way patient care management is handled and practiced. To have effective population health management, healthcare organizations have to be smart about accelerating development of the right areas and manage expectations about what can be achieved.
The Healthcare Industry needs to do a better job of collecting true patient outcomes data, rather than proxies for care. For example, it inherently does not matter if a person with diabetes has had a foot exam—but it matters very much if that foot exam discovers an open wound that will not heal.
Additionally, organizations must also understand cost at a granular, individual level instead of guessing at costs by looking at the average cost of overall patients or members. That approach is almost meaningless when managing margins. Healthcare organizations that have learned and mastered these steps and possess these abilities and capabilities have the essential components for an effective population health management program.
Healthcare delivery systems have never had to deal with the socio-economic and social determinants of health to the degree that public health systems have faced these issues. Healthcare delivery systems must add public health professionals and epidemiologists to their management and executive staff.
They need to build the skills to interact with and develop health intervention strategies in concert with law enforcement; social support services in the community, including charitable and religious organizations; job growth and economic development in communities that ensures people can afford care when they need it; adequate affordable housing in the community; healthy options for eating in the community; adequate dental care; primary and secondary education programs that encourage healthy lifestyles; violent crime reduction; and environmental strategies to ensure that communities have clean air and water.
These are the sorts of issues that public health professionals have been managing for years in the progressive reduction of infectious disease in communities. Now the U.S. needs to follow the lead of other countries and apply those public health skills to the new set of chronic condition management in the community.
Typically, health organizations use different tools such as Business Intelligence (BI) analytical tools to apply population management. Healthcare is transitioning away from a traditional fee-for-service business model to a model that incorporates value into the payment equation thus making the system more accountable. It is, however, a long way to go to equal its peers in the international community. Many health systems don’t have the data and technology to support such transition. The absolute minimal data sets required for this work include:
- patient-reported outcomes data,
- social determinants of health data, and
- activity-based costing data that will allow accurate management of financial margins in per-capita reimbursement contracts.
Without these three pieces of data, an organization can never achieve the aspirations of value-based care—managing populations of health and creating better patient outcomes at an efficient cost.
In addition, Healthcare organizations starting population health will quickly discover that the highest-risk patients from a clinical perspective will not always return the most improved or best possible outcomes. In other words, the highest-risk patients are often those who are beyond the ability to intervene and actually change their outcomes.
While new best practices that deliver better outcomes for these patients may be someday discovered, the reality is that—in a capitated environment with limited resources—there are rising risk patients who will benefit more from those resources and higher levels of engagement.
Population Health and Patient Engagement
It goes much further than just a single patient, in fact, patient engagement services can and should extend to patient care groups and caregivers. There is a large generation of people that don’t have access to computers or don’t have the patience to learn to navigate it or the internet. This doesn’t mean that they should be set aside. Many family members are ever so willing to be an advocate for an ailing relative, and this has been made simpler with healthcare organizations providing nurses and other professionals that can answer questions quickly and help set up appointments when necessary. The result has been that caring for someone isn’t just part of some large abstract machine, but is brought down to individual actions, answers, and information.