Implementing a Population Health Management Program

Are you looking to concentrate on the management of health issues for populations on your premises? If you’re already focusing on population health management do you plan to strengthen your focus? Whatever your position in the monitoring of population health ensure that you have first set objectives to meet in the course of your plan. Any planning activity that is focused on improving the care provided at your location should be based on goals.

I, along with many healthcare professionals that Triple Aim and the Triple Aim of IHI (Institute for Healthcare Improvement) are excellent goals.

The goal is to improve the overall health of the population, improve the outcomes and the experience of the patient and reduce the cost per person of health care in your community simultaneously. I would like to improve your bottom line for providers. The good news is that these goals can be achieved concurrently with the correct approach, although the work is very challenging. Visit:-

In setting and achieving goals for the health of the population in the clinics of providers is an area of focus that is relatively new in the field of healthcare. Fortunately, health departments and epidemiologists have many tools which healthcare providers can utilize or modify. One of them is collecting and analyzing data at an aggregate population level , and then implementing procedures based on research (standardized processes) that impact on the population. Other fields have also used the concept of population-level management to manage their businesses or processes. A lot of these are based on service. I recently completed a population level study for The Salvation Army and an energy service provider.

In the rest of this issue, I’ll describe two population level management programs, and outline some of their methods. Before I go on it, I’d like to point out that population level management could have an excellent ROI for healthcare providers. In a recent online interview of Healthcare Informatics,Robert Fortini, R.N., M.S.N. and chief clinical officer for Bon Secours Medical Group based in Richmond, Virginia, stated that he has seen an ROI of 33% for Bon Secours population level health initiatives. I am convinced that this ROI is possible for many providers that have an effective risk management program.

One medical group working on population level health initiatives are the Hill Physicians Medical Group in the East Bay area of California. The group comprises 3,500 physicians. This group has established virtual care teams made up of social workers, pharmacists Case managers, pharmacists, etc. to support their physicians. Management of population health requires a team approach to be effective. Hill Physician Medical Group works through the ACO model with several of its payors. This system encourages teamwork and eliminates traditional barriers in providing better care. It is as Darryl Cardoza, the CEO of this group, states, “And what the ACO model has enabled us to do is to begin to break down some of those walls, and to help us all work within the same system, and align incentives,” as explained in an interview with Healthcare Informatics.

Cardoza states that population health management is quite different from previous managed care. Based on Cardoza, “It’s not a matter of just preventing people from using certain kinds of resources, but rather, of managing the entirety of their care. And we were doing it by the seat of our pants, because we didn’t have the tools. It was just very, very difficult to use data, to consolidate it and evaluate it and draw meaning from IT; but those tools are available now.” Further, Cardoza states that it is crucial to integrate HIT across provider networks to ensure teams can work more effectively. Additionally, Hill Physicians Group needs to establish a strong relationship to other healthcare providers within the region together with local hospitals, and with health insurance plans. Hill Physicians Group is very focused on becoming a reliable partner for others.

The outcome of their investment in virtual teams with doctors and the linking of their HIT internally and with its partners via healthcare information networks have brought positive financial performance as well as improved health for patients because of better care delivery.

Another organization that is delving into public health initiatives at the level of the population are Bon Secours, mentioned above. The Bon Secours group employed 530 doctors. Robert Fortina stated that “The major bulk of our work has been around supporting our medical home project, and that has involved delivery system redesign, more robust use of technology, and then good old-fashioned nursing-based case management using those tools, so the development has been multi-factorial.”

One component of Bon Secours population management is community (patient) outreach powered by software developed by Phytel. This software generates about 75,000 contact per year. This outreach is based on more than 20 Chronic Disease Protocols and fifteen preventive strategies. This is a solid start for providing better care for their patients. Fortina predicts that in the future, their analytics will become much better and they’ll be able to do better at stratifying patients into risk groups. Doing so will enable them to provide care that is better aligned to the needs of the individual patient.

As you can see, Bon Secours Medical Group and Hill Physicians Medical Group are striving to implement an effective population level health model that is beneficial to both of patients and the healthcare providers. Both of them employ team-based strategies. The return on investment is positive for both groups. Contrasts do exist between the two groups , too. Hill Physicians is a much larger organization and is able to use its size for financial gain. Both organizations use different approaches to care. Hill Physicians uses an ACO model, and contracts with different payers, which makes their approach to care more complex as each payer has different requirements within their agreements. Bon Secours bases its population model on the patient-centered medical home, a long established chronic care model.


Leave a comment

Your email address will not be published.