Managing population health requires healthcare providers to reach out to patients to both prevent and treat sickness. Jonathan Niloff, MD, vice president and executive medical director of population health at McKesson, explains three levels of patient outreach:
1. Reminders. The first level includes simple reminders for patients who are overdue for certain routine examinations, such as pap smears, mammograms or immunizations. A primary care practice establishes a system that identifies patients who are overdue for certain tests and automatically generates letters or other forms of communication reminding patients to schedule an appointment.
2. Follow-up. The second level includes phone calls to follow up on patients after they visited the emergency department or were discharged from inpatient care. Care coordinators call patients to ask them to schedule an appointment with their primary care provider, determine if they filled their prescriptions and educate them about what signs or symptoms might signal a need for additional care.
3. Care plans. The highest level of outreach involves providers using a predictive model to identify a certain percentage of patients most at risk for getting sick. "Once you get beyond the block and tackling of having registries, getting care coordinated and [having] a common set of clinical guidelines is the step of saying 'I want to identify in my population the top x percent of patients who are the sickest and most likely to consume the most resources in the future,'" Dr. Niloff says.
A care manager calls these patients, conducts an assessment over the phone and establishes a care plan to keep patients healthy. The care managers continue to call patients on a regular basis to monitor their adherence to the care plan and their health status. By monitoring patients, care managers can intervene before their condition worsens and forces them to go to the ED or receive inpatient care. By preventing ED and hospital visits, providers can both improve the quality of care and reduce costs, according to Dr. Niloff.