While the concept behind population health is simple — keep people healthy — putting actionable plans that support these efforts into play are extremely complex.
Increasingly, healthcare organizations have sought the consultation and resources of firms specializing in such initiatives.
Greenville, S.C.-based Care Coordination Institute is one example. A young nonprofit, CCI was created by Greenville (S.C.) Health System when it launched MyHealthFirst Network, a clinically integrated network in the upstate region of South Carolina, in 2013.
MyHealth First includes nearly 2,000 healthcare providers across 10 counties. CCI's main goal is to help healthcare organizations identify how to improve population health management by educating providers on care coordination, evidence-based practices and the promotion of healthy lifestyles for people in the community.
Brent Egan, MD, medical director of CCI, has been with the institute since its start, though he has been involved in population health management and quality improvement since 1999. While there are numerous complexities involved in addressing the health of a population, integrated health systems can maintain effective population health management initiatives if they cultivate certain key competencies, according to Dr. Egan.
1. Risk stratification. "One of the first things integrated health systems need to be able to do is risk-stratify patients to understand where the greatest opportunities and risks lie," says Dr. Egan. CCI uses several commercially available software programs to stratify patients into low-, rising- and high-risk for adverse health outcomes and cost — with high and rising risk patients often having multiple chronic conditions.
According to Dr. Egan, clustering of chronic diseases provides opportunities to move beyond individual disease management programs to integrated management of multiple chronic conditions as recommended by the Institute of Medicine in 2001. Among Medicare patients in MyHealthFirst, a 12-cluster model described the patient population well with five relatively low-risk and seven high-risk clusters. The three highest risk clusters of disease contained two-thirds of the highest-risk patients (top 5 percent utilization): the heart failure, renal disease and cancer clusters. Patients that fall into these three clusters typically have six or more chronic health conditions, suffer adverse health outcomes and utilize the most healthcare services. For example, the majority of patients with heart failure had a concomitant diagnosis of hypertension, hyperlipidemia, vascular disease, chronic lung disease and 40 to 50 percent have diabetes, chronic kidney disease and a behavioral health-related issue.
"Instead of developing an individual care plan for each heart failure patient, the opportunity exists to develop a comprehensive, integrated care plan for heart failure and the common concomitant conditions, which often include a behavioral health issue. The 'cluster plan' can then be adapted to the individual patient," says Dr. Egan. The approach of managing the clusters of chronic conditions can help focus care delivery and care coordination on the factors that contribute most to good outcomes for each patient group, while retaining the flexibility to personalize care for the individual."
2. Enhanced care management and integration. The next key competency is assisting with care management and integration. For this, CCI uses Caradigm software developed in concert with Danville, Pa.-based Geisinger Health System, which has devised best practices for managing patients with chronic diseases, improving outcomes and reducing costs. The software captures real-time information from multiple electronic sources and supports ongoing integration of patient care between the care manager, home, primary and specialty care services. It also provides timely notification of emergency department and hospital admissions and discharges and gaps in care. The software allows care managers to focus on what the patient needs for optimal outcomes rather than dividing time attempting to remember and track every element of the evolving care plan.
3. Advance healthcare analytics and business intelligence to inform decisions. Another component of CCI's services are the evidence-based clinical guidelines and care model processes, according to Dr. Egan.
"CCI works actively with clinicians and other members of the care delivery teams to improve care model processes and clinical guidelines," says Dr. Egan. "You can find many different clinical guidelines and care models, but it is important to tailor operations and improvement efforts to the characteristics of the healthcare organization we partner with and the patient population they serve."
A robust business intelligence team that is responsible for producing actionable quality and finance reports, as well as advanced data analytics, helps improve clinical guidelines and care model processes.
According to Dr. Egan, data analytics are critical for a more nuanced understanding of what modifiable variables contribute most to positive and negative outcomes important to each healthcare organization and the patients they serve.
Advanced analytics and business intelligence are critical to the capacity of integrated healthcare systems to achieve the multiple aims of an excellent healthcare experience and outcomes for patients at a cost that is affordable and sustainable. Rapid learning systems are essential to this fundamental transformation of healthcare. In other words, they must learn quickly what works and what doesn't, receive insights on changes that efficiently improve the experience and outcomes of care, and anticipate the future healthcare needs of the population they serve for longer-range strategic planning.
4. Strategic counsel. Integrated health systems in need of assistance identifying pain points and implementing population health management initiatives can obtain strategic advisory services from CCI. CCI provides clients with a global assessment to evaluate business health capabilities, value-based benefit plans and where they can benefit most from partnerships.
5. A 360-degree view. The U.S. healthcare system has focused mainly on medical determinants of health, which account for 10 to 20 percent of the variance in health outcomes, whereas 'social' factors, such as where a person lives, lifestyle patterns, income and social support account for 80 to 90 of the variance.
A database which encompasses a '360-degree' of both medical and social factors provides opportunities to construct a more holistic model in which an integrated healthcare system partners with other community resources and supports in areas of shared goals. Such partnerships have a greater likelihood of effecting changes in a broad range of modifiable variables such as improving education and lifestyle patterns and reducing drug and alcohol abuse, while providing the right care at the right time and place.