Population Health Management: Best Practices for Treating Aging Patients
By Joseph Berardo, Jr.
The prevalence of multiple chronic conditions and functional impairment within the aging population is on the rise. There’s more need than ever for a level of coordination that improves outcomes and lowers the total cost of care. Successful health care and long-term service delivery models must involve a team of providers to meet individual needs, increase access to health care, improve outcomes, and synchronize the various services and supports.
Ideally, population health management (PHM) — the aggregation of patient data across multiple health information technology resources — includes a care coordinator who works closely with patients, as well as their family caregivers, primary care providers, and other health care professionals. The care coordinator’s goal is to foster communication, improve individual well-being and enhance outcomes.
PHM is one of the most promising avenues for thriving in the environment of health care reform. It entails identifying high-risk patients and determining which ones require individualized attention. This means developing thoughtful, patient-centric health care strategies that rely upon predictive modeling and individualized outreach programs.
The health care industry has begun to adopt predictive analytics as a prerequisite for PHM and an important component of any approach to reducing the total cost of care. Predictive analytics put data analysis into a single, actionable patient record, enabling the care team to take actions that lead to better clinical and financial outcomes. These statistical tools are also being used to forecast which patients are likely to be at increased risk for health problems and cost more health care dollars. Some health care organizations also apply predictive analytics to large clinical and administrative data sets in an effort to identify higher-risk patients and intervene before they become seriously ill.
To be effective, however, stakeholders must develop the infrastructure and culture required to turn the data into action. They must have the ability to generate timely reports and use automation tools to apply intervention strategies across a patient population. Predictive modeling shines a light on the top percentage of covered lives that are at highest risk for illness and increased costs. These are the patients who will most likely benefit from PHM programs designed to improve their health and lower costs overall.
This level of state-of-the-art health analysis technology enables users to confidentially assess the health risks of every patient. When risks are identified and need attention, these programs can coordinate personalized guidance for the individuals who need it the most. Having the ability to provide a suite of industry-leading health advocacy services can greatly improve patients’ health and keep health care costs contained.
Individualized Outreach Programs
The goal of an individualized outreach program is to develop a healthier population over time. Such a program should be designed to evaluate the overall health of a plan population and identify participants who have common and costly chronic health conditions or who are at risk of developing them.
It’s important for health care organizations to find ways to target participants they can invite and encourage to enroll in a program that helps them improve their health. The program should have the capacity to analyze collected health data — such as emergency room visits, hospital admissions, and pharmacy claims — to identify plan participants who have or may develop chronic health conditions such as diabetes. Patients are then stratified according to predetermined metrics.
Upon enrolling in the program, participants should have access to a registered nurse after completing a comprehensive health assessment. From there, customized care plans can be developed to achieve individual health care goals and optimize participants’ involvement in managing their chronic conditions. In addition, nurses should manage the identified risk population through telephonic and on-site outreach. By doing so, nurses can give patients education, support, and access to tools they need to better handle their health.
It’s important for participants to have a trusted contact they can reach out to with questions, concerns, and choices regarding their health. Nurses can fulfill this role for high-risk patients and work with providers to:
improve quality of care
improve patient contact
increase compliance with treatment
improve knowledge and professionalism
improve patient quality of life
assist with provision of skills for self-care
provide and reinforce patient education
improve patient satisfaction
In PHM, the objective is to minimize costly, yet often unnecessary or redundant, interventions. To be effective, health care organizations must focus on high-risk patients who generate the majority of health costs. They must also pay attention to the preventive and chronic care needs of every patient, all of which makes access to transparent health data crucial.
In addition, tracking health care data can serve as the foundation for quality improvements and changes in clinical behaviors. A study by The Wisconsin Collaborative for Healthcare Quality found that tracking the quality of care encourages physicians to change the way they practice medicine, increasing the likelihood of them following guidelines more strictly.
For providers, transparent health data provides:
Standard metrics for assessing quality of care
Outcome- or performance-based payment
Knowledge of prices paid to hospitals, labs, and specialists to inform patients
Transparent health care data is vital for curbing costs and changing patients’ behavior patterns. In fact, data analysis serves as the backbone of wellness and PHM strategies, and leads to greater efficiency and effectiveness.
Automatically aggregating and consolidating data from a variety of disparate systems and sources, including inpatient, ambulatory, and home sites, has been shown to improve the continuity and efficiency of patient care. Toward that end, a number of provider organizations are striving to connect data silos and enhance transparency.
Reducing costly future medical care leads organizations’ health care costs to go down while patient health improves, making this approach a win-win for stakeholders.
Barriers to Effective Use of Transparent Data
In the past few years, there has been an explosion in public and private reporting of health care costs and quality data. So far, the results have been what many believe to be an inconsistent and at times a distorted set of quality-reporting measures. A lack of coordination and consistency of data can also undermine the opportunity to lower health spending based on potential for quality and price.
The problem is further exacerbated by the fact that so few organizations have the experience to perform meaningful analysis on the data that would allow it to be translated in a way that will foster positive behavior change. The key to taking advantage of the data is to find a way to take the burden of data collection off of providers and simplify the information.
As elder and chronic care shifts toward value-based payment models that compensate physicians based on patient care and outcomes rather than frequency of services, quality becomes paramount. Under traditional fee-for-service payment models, there was no real incentive for providers to reduce unnecessary care.
A PHM plan that is patient-centric, involves predictive modeling, and includes individualized outreach programs — all built upon a foundation of transparent data — will become the standard.
Predictive modeling allows users to assemble all of their patients’ health data, including past claims and medical records, and process it through a comprehensive health analysis system. The system identifies patients who are at highest risk for serious health issues, so providers can make a suite of proactive health advocacy services available immediately.
Furthermore, data that measures health care prices and quality can serve to demonstrate value, treatment outcomes, and level of access. In particular, a well-coordinated PHM program for aging patient populations depends upon such information to lower the total cost of care. Strategies designed to optimize this opportunity have potential to help close the gap between the high rate of U.S. health care spending and current levels of quality and access.
About the Author: Joseph Berardo Jr. is CEO of MagnaCare, an administrator of self-insured health plans for employers in New York and New Jersey.