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Population Health Management (PHM) Cheat Sheet by

Public Healthcare
management     public     healthcare     population

Introd­uction: What is PHM?

PHM is a model for helping providers and payers assess the popula­tions they serve across the continuum of care. It involves the strati­fic­ation of patients into well-d­efined risk groups and the creation of differ­ential care strategies based on each group’s needs. Its goal is to reduce costs by preventing those who are well from becoming ill and improving quality of life and enhancing health outcomes for those who have developed one or more chronic condition.

PHM focuses on

1. Identi­fying and supporting the sickest patients
More than 133 million Americans, or about 45% of the popula­tion, have at least one chronic condition, which accounts for more than 75% of national health care spending. Identi­fying these high-risk patients early and implem­enting proactive disease and case management programs will enable providers and payers to cut down on inappr­opriate spending and improve patient care.
2. Minimizing or preventing the progre­ssion of disease.
According to the Institute of Medicine’s Crossing the Quality Chasm report, about 50% of Americans with chronic illnesses are not receiving recomm­ended care. Providers and payers will need to work together to verify physicians are abiding by medical best practices and patients are adhering to their treatment plans. Through robust data analysis, gaps in care can be identi­fied, preventive measures taken and risks mitigated.
3. Promoting a culture of wellness
Central to an effective PHM model are informed and involved patients who partic­ipate in setting their own goals for wellness. Hence, providers and payers will need to design targeted, long-term strategies that drive patient engagement and promote healthier behaviors. Moreover, the necessary infras­tru­cture must be in place to gather patient inform­ation not only at the site of care, but also remotely, as trends indicate that health care will be delivered in the lowest­-cost and most efficient enviro­nments, such as the patient’s home. An effective PHM program will keep patients as healthy as possible, which will in turn maximize the value of coordi­nated care and minimize the need for high-cost interv­entions such as emergency department visits and hospit­ali­zat­ions.

Public Health Management

Five steps for moving forward

Into the future: achieving effective PHM Building a sound PHM program requires functional effici­encies and operat­ional effect­iveness — all based on a solid, integrated strategy.
1. Define your target population and its needs
The target population could be your entire service area or any subset, whether economic, geographic or demogr­aphic, or patients with certain medical condit­ions. Identify the health status and needs of that group and the health and wellness services that will best address the risks identi­fied.
2. Set, measure and monitor program outcomes
Once you begin a program, effect­ively tracking outcomes requires the ability to gather, coordinate and collate data from care providers across the care continuum, as well as from payers, pharmacies and individual population members. Gathering and leveraging this broad set of data typically calls for new or more mature capabi­lities in your clinical inform­atics group.
3. Develop the technology infras­tru­cture for data analytics and reporting
Providers can begin by leveraging payers’ infras­tru­cture and heritage with analytics. With more robust EHRs, providers will not only have connec­tivity among all parties collab­orating in a patient’s care, but also more real-time feedback on how each provider organi­zation is adhering to its own guidel­ines, using data with more richness and specif­icity. Alerts and follow-up can be moved more rapidly to approp­riate caregi­vers.
4. Manage the growth in demand for IT servic­es.
PHM will spur new IT demands, including increasing storage and processing capabi­lities, developing and deploying web and mobile tools to enable full consumer partic­ipa­tion, and building health inform­ation exchanges. Chief inform­ation officers will need to set priorities and manage expect­ations.
5. Expand partne­rships
To realize the benefits of PHM, providers and payers will need stronger collab­ora­tions that bring access to rich data sources.

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