"Population Health Is Your System Ready for Population Health Management? By Dale J. Block, MD, CPE Beeause of these forées, health eare systems and pro- In this article... viders are facing a new business model foeused on providing eomprehensive health eare serviees while managing the risk Health care organizations will need to migrate to for the eosts of care to their patients. population health management sooner rather than Researeh discussed in the report suggests that all later in response to statutory and regulatory pressures health eare organizations must ereate a transitional path coming from the federal government. to population health management sooner rather than later. The report outlines several critical elements to this trans- formation ineluding: In 2011, the Health Care Advisory Board's Care • Developing clinieal deeision-making. Transformation Center published "Three Key Elements for Sueeessful Population Health Management." This researeh • Establishing a primary eare-led elinieal workforce. briefing began by identifying some thought-provoking ques- • Initiating patient engagement and eommunity tions for health system leaders planning and preparing for integration with local eonstitueneies. population health management: 1. What businesses should we be in? Developing information-powered clinieal deeision- making requires the use of robust patient data sets aequired 2. Who will our partners be? along the continuum of eare that support proactive, preven- 3. What is our role in the communities that we serve? tive and eomprehensive medical eare, operates within an integrated data network, and positions a physieian leader to merge complex data analytics with elinieal eare proeesses. These questions arise beeause of accelerating environ- Establishing a primary care-led clinieal workforce mental forées that are causing major ehanges in the delivery elevates the primary eare physician to what amounts to of health eare serviees in the United States today. These CEO of the patient eare team and mobilizes a community forées include: workforee to extend the eare team reaeh to where people live and work. • Enrollment in Medicare is elimbing exponentially as the Initiating patient engagement and community inte- U.S. population ages. gration with health system's local eonstitueneies will map • The big data revolution is exploding with increasing IT health eare serviees to population need. The effort must infrastructure and data analytie requirements along the overeóme nonelinieal barriers to maximize health outeomes continuum of care. and safety, integrate patient values into personalized individual eare plans and use eommunity stakeholders to • The incidenee of chronie, preventable disease is reaching connect people with high-value health eare resourees. epidemic proportions. • The inereasing statutory and regulatory requirements Developing clinical decision-making are eoming from the Affordable Care Act. The information health care eeosystem is rapidly changing. Population health management requires health 20 PEJ MARCH-APRIL/2014care organizations to focus on iden- tifying and using patient data and information collected along the con- tinuum of care that will support evi- dence-based clinical decision-making. Today, many health systems have begun the arduous task of building toward data integration based on real- time clinical information from mul- tiple patient access points of care. This will provide a competitive advantage for early adopting health systems and offset the high opportunity cost of developing their IT infrastructure to meet these new demands. Robust patient data sets collect- ed along the continuum of care will connect individual patients to their primary care physicians in ways that will allow for predictive modeling of future health care issues. Adding an individual's complete genome (now Health care organizations will need to acknowledge the role of community health care available commercially at a very rea- workers in the delivery of non-clinical care services. sonable cost), means personalized health care delivery will no longer be a dream, but a reality. Businesses and the community of patient information. Thus, ongoing A customized diagnostic profile, access to and analysis of patient health at large are demanding proven clini- including a physical examination cal programs that have the greatest information regardless of its place of and detailed biomarker analysis, will origin is key to providing proactive, measurable impact on quality, safety individualize care plans for not only and outcomes while simultaneously preventive and comprehensive care. the present, but also the future. Real- This integrated IT approach to patient lowering the cost of care. This is the time ongoing biological screening value proposition for health systems information leads an organization and self-management reinforce the along the continuum of developing a as they design and develop their individualized care plan. Primary Accountable Care Organizations culture of value-based health care. care physicians will be able to have (ACOs) for a competitive edge in Challenges for every health care an accurate assessment of an indi- their individual marketplace. organization are to leverage and apply vidual's health status and intervene complex data analytics for clinical before problems occur, thereby deliv- Establishing a primary information collected along the con- ering the most appropriate care at a tinuum of care. System leadership will care-led clinical workforce lower opportunity cost. need to identify a physician champion According to the Health Care As data becomes universal, with the appropriate knowledge and Advisory Board's report, advances health care organizations will dif- credibility to lead this effort. CIOs in information-driven health care ferentiate themselves from each and CMIOs will continue to focus on delivery will have a profound impact other by what they do with that data. building, refining and maintaining on the current and future clinical Designing and implementing inte- the IT infrastructure for the system. workforce. Leveraging integrated grated data networks will leverage The chief of population health man- clinical information gathered and patient information sharing across agement, the "CPHM", has critical organized through complex analyti- platforms within an organization and operational responsibilities includ- cal data systems will greatly depend across independent providers. ing mining clinical and operational on the health care providers connect- Health information exchanges are data, distilling best clinical practices ing directly with patients along the increasing rapidly along the IT land- across their organization and creating continuum of care. scape. Individual organizations will templates for information-driven care Advances in technology will also no longer have proprietary ownership plans for patients. allow health care providers to extend ACPE.ORG 21Population health managers need to build connections across the entire continuum of care. the reach of the clinical workforce • The ability to coordinate and This model fits into the proac- deep within the communities they manage nonclinical personnel tive, preventive and comprehensive serve, managing larger virtual clinical working within the community. model of team care resulting in sys- teams and panels of patients to help tems meeting their value-based goals Health care systems will need to improve overall population health. (i.e., fewer inappropriate emergency promote physician-led, professionally There is great concern by many room visits, hospital admissions and managed care teams that are scalable in health care that the critical issue readmissions). across the continuum of care within for primary care will be a shortage the system. This ultimately requires of physicians in the years to come Initiating patient that primary care physicians will as older physicians leave the work- engagement need extensive training in team man- force and younger physicians migrate The last critical element of popu- agement. Additional consideration toward specialty care. lation health management shifts the will be to align incentives for team Filling this widening gap will focus for health systems outward care to population health manage- require a significant paradigm shift for toward the patients and the com- ment goals. Finally, the long-awaited all health care organizations. Health munities in whieh they serve. This changes in compensation methodol- care systems will need to build com- change in foeus is new territory ogy for team care will drive quality prehensive primary care teams, with for many health care systems. The measures in and productivity mea- the primary care physician working Health Care Advisory Board's report sures out. as the "CEO" to manage care across a provides insight for health systems Of great interest to many will range of providers including advanced for managing this shift. be the mobilization of a community practitioners, nurses, social workers, According to the report, the workforce to extend the care team pharmacists, nutritionists and others. challenge for health systems today reach. These individuals will be non- The priority will be to enable top-of- in becoming a patient-centered elinical workers (e.g., community license practice for all professionals in enterprise is accepting that people, health workers) who can help patients the care team. in general, do not want to be con- navigate the health care system and The CEO physician will be sidered "patients." Accepting this peers such as diabetic patients who the team and operational manager premise places health care providers can provide ongoing health coach- making leadership decisions for outside of the sphere of most people's ing and support to others that share the group. This individual must be day-to-day activities. In order for chronic disease states. service-oriented with strong inter- health systems to migrate toward Community health workers have personal skills. Additional skills may value-based care, it is imperative for been involved along the periphery of include financial, operational and the system to integrate into people's health care delivery for some time. clinical information capabilities. daily lives. These individuals, living and working Finally, traditional business compe- Population health managers need in their communities, become trusted tencies such as leadership, strategy to build connections across the entire resources by bridging language and and delegation of care services are continuum of care, both traditional cultural barriers between patients critical elements for success. and nontraditional. Matching and and the health care delivery system. Care team members will need to mapping health care services are As care teams become imple- posses the following characteristics: critical success factors in meeting mented, health care organizations community health needs. will need to acknowledge the role of • Effective communication skills. Reaching out to other organiza- community health care workers in tions delivering health and social • Teamwork ethics that promote the delivery of nonelinical care ser- services to the community builds a top-of-license practice. vices. The reach of health workers seamless continuum of patient-cen- into the community will bring indi- • Strong critical thinking skills. tered care. This collaboration is fos- viduals requiring health care services tered through open communication • Comprehensive, longitudinal and into the most appropriate access and allows for a significant reduction proactive patient care focus. points for care. 22 PEJ MARCH-APRIL/2014in duplication of community offer- Acknowledging and addressing non- of improving the health of the commu- ings. Strengthening options across the clinical challenges outside of normal nity. Population health management continuum of care can simultaneously primary care structure improves requires identifying people who are at improve utilization patterns and better clinical outcomes, especially for the risk for disease and bringing them into serve the community needs. highest-risk patients. the system. This allows for managing Overcoming nonclinical har- Often overlooked by the care underlying health problems before they riers to maximize health outcomes become acute, requiring higher costs team is considering integrating is the greatest barrier to improving patient's values into the care plan. To of care. To do this, partnerships with individual health. According to the other organizations in the community be truly patient-centered, health sys- report, social barriers (e.g., age, gen- are crucial. Credibility, transparency tems must acknowledge that patients der, impairment) and financial barri- and accountability are key to connect- are people first. This should factor ers, not clinical issues, lead to poorer ing patients with high-value resources into care planning especially for health care outcomes for those who in health care systems. those with end-of-life issues. are chronically ill. Transportation By discussing personal goals, By embracing key elements for problems, medication use, adherence clinical care can be delivered more successful population health man- to medical treatment and other public efficiently and effectively by using agement, health systems will get to health issues such as adequate shelter, less costly venues while still providing value-based care more efficiently and nutrition, sanitation, etc., require the maximum levels of health care ser- effectively. Identifying a key physician assistance of nonclinical community vices such as hospice care based on the leader and allowing this respected resource specialists to work with care wishes of the patient and family. The clinician to distill the principles and teams to influence health outcomes. critical success factor is initiating the practices of population health manage- This approach allows everyone on proactive discussion before admission ment throughout their organization the clinical team to work at the top-of- will promote acceptance of this new to the intensive care unit. license while having important non- model more quickly by all who will be Health systems' biggest challenges clinical issues addressed and resolved. delivering health care services. will be accepting the responsibilities With the Affordable Care Act forcing implementation of several statutory provisions beginning this year, failure is not an option for most health care organizations. Careful and ongoing strategic planning is required because of the rapidly changing land- rnina healers into leaders. scape in health care delivery for the next few years to come. A use Master of Medical Management degree • Get the business skills you need to lead in today's health care environment. Dale J. Block, MD. CPE, • You'll earn your degree in just over a year without is a full-time practicing ^,== % interrupting your career. family physician with Premier Family Care of • Earn your business degree from an Mason in Mason, OH. internationally ranked business school. djblock5@gmaiLconi. Call today to find out when classes begin. Call 213-740-8990 or use Marshall learn more online at MASTER OF MEDICAL MANAGEMENT PROGRAM www.marshall.usc.edu/mmm 24 PEJ MARCH •APRIL/2014Copyright of Physician Executive is the property of American College of Physician Executives and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use."