Hospitals throughout the country are developing or in the process of considering development of programs to effectively manage population health.
The specific goals of these programs may vary from institution to institution, but they tend to center around several objectives, including:
- increasing years of life and the quality of those life years for the institution's community;
- reducing the differences or disparities in health outcomes among different population subgroups;
- cost reduction; and
- meeting the mandates of value-based reimbursement.
While programs may differ, what typically does not are the critical core components of successful population health programs. These can be broken down into foundational components that, when combined with effective team engagement components, should serve as the basis for launching or further developing a successful and sustainable population health program.
5 Foundational Components
At Avanza Healthcare Strategies, which provides healthcare organizations with strategic guidance, with a focus on population health management and outpatient services, we have identified the following as five essential foundational components for a population health program.
1. Focus on outcomes. Successful population health programs focus on specific outcomes and then develop processes to achieve those outcomes. While that approach may allow an organization to use some existing processes and relationships, it may require an organization to do everything needed to achieve success from scratch if existing processes and relationships do not support the most effective way to bring about those outcomes.
For example, if an organization identifies a need in its community to focus on reduction of pre-pubescent obesity and its negative health impacts, that is the outcome. The organization should now work backward, building the framework for the program around what it determines is necessary to achieve improvement in the fastest, most effective and sustainable means necessary. If that framework includes working with school nurses but the organization does not have strong relationships — or any relationships — with school staff, this component should not be removed from the program. Rather, the organization will want to determine how to develop these relationships, which may include partnering with another organization that has relationships with school nurses or bringing in new staff who can build these relationships for the organization.
While it may be easier for an organization to just use its existing processes and relationships to launch the program as opposed to putting in the effort of forging new ones, the program is more likely to stall and fail to fully achieve its desired outcome once the limitations of existing processes and relationships are reached. To fully reach its potential, each program should be unique and built specifically to match that outcome. In order to know if programs are truly successful, there must always be a comprehensive evaluation component for every intervention.
2. Collaborate with existing community-based entities. To maximize the success of population health programs, hospitals cannot operate them in isolation. Doing so will limit the programs' reach. Even a hospital heavily involved in its community is not likely to have contact with all of its target population.
To increase the number of people engaged in a population health program will require collaboration with organizations and individuals who work outside the walls of the hospital and its satellite locations that provide services impacting community health.
These community-based entities include groups involved with economic development, housing, legal services and youth leadership. As in the example noted above, it may include schools. These non-traditional partners can help identify barriers to access and promote patient engagement.
3. Develop healthcare homes. For population health programs to be successful, organizations must examine whether their facilities can effectively serve the needs of the target population. Effectiveness should be analyzed several ways, including whether the target population will feel comfortable receiving care and disclosing risky behaviors at those facilities. While a hospital may have the manpower to provide care to the population, that does not necessarily make it the best choice of a location to serve a population.
Let's revisit the example of a population health program that aims to reduce pre-pubescent obesity. Parents may not want to bring their child to a hospital or go to a hospital themselves to receive education or an intervention. A hospital is often not viewed as an inviting location by many populations, especially people who see themselves as healthy and well. Rather, a hospital is identified as a place to be avoided unless it is absolutely necessary.
Organizations will want to take issues such as cultural sensitivity and literacy (and others that will be discussed below) to determine the best possible locations to drive the program. To combat pre-pubescent obesity, for example, an organization may want to engage in discussions and collaborations with primary care providers, federally qualified health centers, school nurses and even YMCAs as their locations may prove to be more effective or at least a complement to the organization's existing locations.
When a target population is provided options on how to participate in a program — and those options cater specifically to their needs — it is more likely for the program to achieve short- and long-term success.
4. Take into account impact of social determinants. Social determinants of health are the conditions — both economic and social — that influence health. These conditions are affected by the money, power and resources available to individuals and communities, and they ultimately impact health outcomes. Examples of social determinants contributing to health inequalities include poverty, unequal healthcare access, lack of education and barriers based on language and culture. It is critical for hospitals to take these conditions into account when developing population health programs, and work to remove these barriers to wellness to better achieve health equity.
Where poverty is present, the program should work to provide low or no-cost services. When members of the community cannot access services, those services should be brought to a more accessible location or provided through other means that remove location as an obstacle. When education is lacking, education must be provided. When lower outcomes can be tied to individuals' language and culture, resources must be dedicated to ensuring the program is accessible to those speaking different languages and caters effectively and appropriately to people who come from different cultural backgrounds. Also, a clear understanding how impactful the determinants of health are in decision-making must be taken into account in designing effective population health programming.
5. Implement patient-centered interventions. While the framework for a population health program should focus on planning for the entire program, it is important that organizations take into consideration the different populations within that broad population and whether these populations — and even individual members — may require different interventions.
Let's once again consider a program targeting pre-pubescent obesity. If 100 second graders are a target population for the program, interventions should be planned to effectively impact all 100 second graders. But if some of these second graders come from poorer neighborhoods while others come from wealthier areas of the community, it may be necessary to plan different interventions that take this factor into consideration. The motivators for change between these two populations may differ, so a program that does not take this into consideration is not likely to achieve across-the-board benefits.
Even if just a single second grader has a social determinant of health different than the other 99 students but it is one that is likely to impact the program's effectiveness on this individual, it may be necessary to develop interventions solely for this student.
Population health programs do the most good when as many members of the population can be helped as possible. While it is likely that some members will not benefit as much as others, it is an organization's responsibility to do all it can to increase the program's overall success rate.
5 Team Engagement Components
At PicketFenceConsulting, which focuses on organizational development through strengthening
communication and coaching processes with cross-functional teams, leaders, physicians and staff, we have identified the following as five important components to effectively engage team members in a population health program.
6. Hire smart. To lay the foundation for a successful team — and one that will be eager to support and drive a program forward — begins with finding and hiring the right team members. A strong hire begins with a thoughtful interview process. Organizations are often too focused on addressing an immediate need around filling vacancies quickly. Adopting a more thorough assessment process results in more successful hires and lower cost in staff turnover.
Managers should be trained to focus not only on skills and experience, but also personality and culture fit in the organization. We work with our clients to adopt scenario-based interviewing strategies in selecting medical assistants, nurses and other front-line staff roles.
As opposed to simply asking candidates to share successful or challenging experiences in prior roles, provide specific examples of situations faced by staff in the organization and ask candidates to articulate how they might respond. Encourage managers to role play brief telephone or in-person interactions with candidates in order to get a sense of how the candidate might respond in a given situation.
Organizations should take the time to develop sample scenarios specific to new population health programs for optimal impact. As with the previously described program targeting childhood obesity, scenarios assessing age-appropriate health education and family interactions will provide hiring managers with an actionable view of how candidates will perform in their specific setting. Additionally, the onus rests with the hiring manager — and organization — to assess not only the skills and backgrounds of presenting candidates, but also the professional commitment candidates possess to serve a target population.
By taking the additional time and effort to screen for "true fit" in the organization, managers will find their talent pool improving as they fill positions.
7. Train for interaction style. Ongoing staff training is too often focused strictly on clinical process and organizational policies and procedures. Organizations that take the time to provide training on "how" staff are interacting with patients — not just "what" they are saying — will find improvements in their patient satisfaction outcomes and patient loyalty.
Front-line staff in healthcare roles are often used to "following a script" or making sure they have answered all of a patient's questions, and sometimes forget that mastering the basics of good communication mechanics — tone of voice, body language and eye contact — will have great impact on how they are perceived by patients.
In many programs, staff will have to adapt their interactions significantly to serve the range of individuals in their target demographic. It is important that managers identify a particular staff member's aptitude in a range of interactions. For example, a nurse may be excellent in interacting with and educating youth in the child obesity program, but require coaching to effectively interact with parents and caregivers. Coaching must be matched to staff member's specific needs. Managers may sometimes feel outside of their depth in providing coaching on these skills and need the organizational support and buy-in in order to do so.
8. Coach in the moment. Coaching opportunities are often reserved for formal meetings or reviews or in the worst-case scenario of when a staff member is underperforming and receiving corrective action. Organizations should realign their coaching philosophy to take frequent opportunities to talk about staff behaviors when they are actually happening — that is, in the moment.
Behaviors that exceed expectations should receive as much attention as those that may need improvement. A manager taking a moment to share, "Becky, thanks for treating Mrs. Wong with respect and dignity, even during such a challenging interaction about her bill," will have positive impact not only on the individual staff member hearing the positive feedback, but also her colleagues who overhear the feedback.
Building a culture where desirable behaviors are encouraged and praised helps staff to feel noticed and valued. Similarly, do not wait to point out areas of opportunity. Managers should feel empowered to take a staff member aside to address problematic behaviors quickly and specifically, which helps build a culture that is not punitive but rather fosters growth and skills development.
9. Nurture and maintain staff and physician alignment. Organizations must look for opportunities to keep staff and physicians aligned. We encourage our clients to provide opportunities for both groups to gather as a team for activities like periodic "lunch and learn" sessions or short team-building meetings. Instances where both groups can come together to debrief on successes and challenges not only builds unity but also helps to break down communication gaps and challenges that may be emerging on-the-line that managers aren't fully aware of.
Front-line staff are an organizations best promoters of their physicians. Maintaining positive alignment results in not only decreased staff turnover, but more word-of-mouth referrals as staff members are able to authentically share about the physicians they work with.
10. Support a culture of UPR. We talk quite a bit with our clients about the concept of unconditional positive regard (UPR), both in respect to staff-patient interactions as well as inter-staff. The tenants of UPR are fairly simple: mutual respect, clear communication, leaving personal issues outside of work and honoring the duty of caring for patients.
Staff members who struggle with maintaining a consistently professional, kind and positive demeanor are often allowing a personal perspective to interfere. And while it happens to all of us at one time or another, organizations — and their managers — have a responsibility to set the bar high. This can be especially critical in situations when serving under-resourced populations where patients can already feel marginalized by their health system. Reminding staff that challenging patients deserve the same level of respect and customer service as any other and that staff conflicts ultimately result in decreased patient care are examples of maintaining clear expectations, and ensuring every interaction is aligned with the organization's values.
Joan Dentler (jdentler@avanzastrategies.com) is president and CEO of Avanza Healthcare Strategies (formerly ASC Strategies), which provides healthcare organizations with strategic guidance, with a focus on outpatient services and population health management. For more than 25 years Ms. Dentler has been consulting on, developing or operating hospital outpatient services, ambulatory surgery centers and community health initiatives.
Jason Davidson (jason@picketfenceconsulting.com) is founding principal of PicketFenceConsulting, a firm which focuses on organizational development in hospitals, surgery centers, medical groups and other providers through strengthening communication and coaching processes with cross-functional teams, leaders and physicians.
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