Population Health Management….Finally!

Those of us in the healthcare industry have for years been talking about the need for more coordinated, patient-centered care; though to actually have a system-wide change in the way we deliver care has been slow to come. We continue to be an episodic, sick-care system, but (!) now there is payment reform on the horizon including shared risk models. Health systems are feeling the urgency to care for their populations rather than individual patients in order to better manage cost and improve quality. Focus is shifting to prevention and proactive chronic disease management.

Without doubt, this is an exhilarating time, though there are definitely some challenges in this new and quickly evolving population health space. This means we are seeing increased need for data aggregation, analytics, registries, care management work flow tools, and even patient engagement tools. Care managers, clinicians, and administrators want to be able to easily access data about their populations across the continuum of care, and in a way that allows them to act upon it.

Vendors are sensing this urgency and picking up the pace to meet this need. It’s no longer about just analytics, but about the action that results from that data. Vendors are hard at work developing new functions to add to their repertoire, others are adding new companies that already have those functions; then, integrating those functions into a single product.

Although vendors are scampering to figure out the quickly changing market and meet its needs, health systems are still trying to figure out what population health management means exactly, and how to make it happen within their organization and community. Historically care management occurred in silos, at each separate facility. Now we are looking at coordinated care not just across an organization, but across a community including primary care, long-term care, home health, and even wellness programs.

Therefore what becomes key in this environment is the data aggregation across multiple disparate systems that combines information into a longitudinal patient record. This way the defined resources at the organization level, as well as at each point of care have full access to that patient’s entire community record for clinical decision making. Also key is to have data present in defined cohorts, and in a risk-stratified manner. This ensures the ability to look at a population in an organized, prioritized way; addressing the most at-risk patients first so intervention can occur early, preventing exacerbation or emergency.

This is an exciting time for those of us who have seen the quality and efficiency of the current healthcare system struggle. It’s a time when we will truly see a shift in the way care is delivered, and subsequently see outcomes that reflect that. What we anticipate, and hope the outcomes will be, are a better patient experience, better quality of prevention and management, and decreased cost.

That sounds like a lot to ask. Is it a fantasy? I suppose only time will tell.

To learn more about Impact Advisors’ Population Health Management consulting, contact us here.