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Two Keys for Population Health Success

Population Health management and success will drive Healthcare for the next several years as mandated by the Affordable Care Act (ACA), Value Based Purchasing (VBP), Accountable Care Organizations (ACO) and multiple other federal and state endorsed programs. Everyone is scrambling to figure out how to achieve the Triple Aim (improved quality, lower costs and better patient satisfaction) which essentially wraps up everything with a nice little bow. But HOW can we enable Population Health and make it a win-win situation for patients, providers and payers alike? There are two key components which have to be addressed to make Population Health management a success. The first one is physician alignment and the second one is geo-specific demographic analytics.

Two Keys for Population Health SuccessLet’s examine the first, physician alignment. As Philip M Oravetz, M.D., Medical Director for Accountable Care, Ochsner Health System, wrote: “In many respects, finding the right information technology solutions is less of a challenge than re-defining the delivery of care. For us, creating a synchronized strategy to align all physicians around population management is the big challenge.”* This is certainly echoed across the country by many provider and payer organizations. Getting buy-in from the physicians who are on the front lines, both in academic and the community settings, is crucial to successful Population Health management. Effective change management strategies must be established to ensure a positive end result. One of the most important changes should be assuring physicians that all of the additional work associated with Population Health management will not fall into their hands to complete. Teamwork, particularly allowing licensed care providers to practice to the full extent of their licenses, will enable and extend the reach of the physician to a wider population and will help streamline workflow. In addition, providing incentives and empowering these physicians with the appropriate tools and analytics will allow them to visually understand the impact of their efforts to improve care. This, in turn, reaches the center of the circle, the patient, enabling improved care and satisfaction.

Secondly, geo-specific analytics for Population Health management are sorely needed. How can we manage a population of patients if we do not fully understand the depth and breadth of their socioeconomic, demographic and medical situation? How can we really tailor a health and wellness program if we only have one or two pieces of a puzzle? Currently, many provider and payer organizations have EMR and claims data and are working toward developing an Enterprise Data Warehouse (EDW) to blend these together to provide insight into specific patient populations such as diabetics and heart disease patients. What programs can we develop to go beyond? Could adding geo-specific analytics to the mix enhance referral patterns and improve compliance? As an example, Estella Geraghty, MD, lead author of the outcomes disparities article and an assistant professor of clinical internal medicine at UC Davis, mentioned that tailoring resources and discharge instructions specifically using geospatial mapping around the patient’s home location could be an added benefit and help with patient adherence.** Or as Dr. Tom Frieden from the CDC just commented on preventable death in the US, “These deaths are not random. They are clustered by geography, by state, and that’s a reflection of the huge impact that healthcare policies can have. It is important that we move the needle on programmatic changes and policy changes that increase people’s likelihood of living free of disease, injury, illness, that could be prevented by action that we can take together.”*** Even more recently, researchers from the Perelman School of Medicine at the University of Pennsylvania used geospatial technology to map “hot and cold” areas of the country for stroke related deaths. This could be crucial in Population Health management as it could allow those areas with double the median stroke death rate to specifically target those high risk populations for intensive interventions.**** Imagine the possibilities if we incorporated additional information on the local factors that could be contributing to worsening of disease and work to improve that?

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Dr Marcie Stoshak-Chavez

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