Optimizing population health management

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Terri Maxwell, PhD, APRN
Terri Maxwell, PhD, APRN

As the healthcare industry strives to achieve the Triple Aim, those organizations and coalitions who are holding themselves accountable for the most seriously ill patients undoubtedly face some of the most prodigious challenges. This fragile population, which represents a growing portion of the Medicare population and overall program expenditures, is a source of continuous discussion and growing concern. About 5% of the population — those most frail or ill — accounts for nearly half the spending in a given year.

For executive leaders in the long-term care and related industries, the emphasis continues to be on ways to deliver excellent care and improve health for these individuals, at lower total cost. Many now recognize the value of a Population Health Management approach to shift the focus from care provided and paid for at an individual level to managing and paying for health care services for a discrete or defined population – such as the members of a health plan.

Defining PHM

PHM includes collecting and analyzing member data and managing specific diseases within that population. But these activities are only part of the definition. Broadly defined, PHM is a discipline within the healthcare industry that studies and facilitates care delivery across the general population or a group of individuals. It emphasizes empowering providers and payers (care managers) with information about their patients/members to help improve care and clinical outcomes.

A key component of PHM and will be a priority in the delivery of value-based care going forward is sophisticated predictive analytics. These analytic approaches are key to identifying those high-risk members with advanced illnesses who would benefit from additional services who might otherwise go undetected by traditional means.

This is far more than data gathering, with some PHM solutions capable of “predicting” which patients are more likely to experience hospitalization, readmissions, ICU days or other interventions.  

Making data actionable

Caveat emptor: A number of PHM "solutions" are little more than sophisticated data gathering systems. However, to effectively impact care for those individuals who are identified as the sickest members of a health plan, payers need more than access to the data.

Successful models require both data and clinically driven approaches. Without the proper infrastructure, staffing and resources to intervene when something is predicted to happen, the potential of utilizing patient data will fall short. To achieve goals, analytics must be combined with evidence, clinical protocols and patient outcomes.

Community-based palliative care

Implementation of community-based palliative care to improve outcomes for the seriously ill is one of the most productive opportunities to make data and predictive analytics actionable. New, innovative models now available from niche companies are able to deploy an interdisciplinary team of highly skilled, palliative care nurses and social workers in the patient's home to review and manage symptoms, address gaps in care, establish goals of care and develop care plans in conjunction with the treating physician.

This additional level of support includes providing strategies to relieve pain and other symptoms, supporting patients in treatment decision making and offering emotional and spiritual support to patients and caregivers.

Evidence shows that, with or without curative treatments, a palliative approach offers the best chance of maintaining the highest possible quality of life for the longest possible time.

Shared decision-making

These palliative-trained clinicians have the expertise and sensitivity to conduct meaningful, thoughtful conversations with members, families, caregivers and providers regarding end-of-life healthcare decisions.  This results in shared decision-making and advances a clear understanding of what members and families view as important at the end-of-life. This helps to match treatments to informed goals of care, avert costly, often unwanted interventions of questionable benefit and avoid inappropriate deaths.

Cost savings are a by-product of improving care coordination and reducing unwanted and unnecessary hospital utilization while at the same time enhancing patient and family caregiver satisfaction with care received.

Benefits of care coordination

Palliative interventions further extend the value of PHM by providing timely, appropriate and better coordinated care. Care coordination is identified by the Institute of Medicine as a key strategy that has the potential to improve the effectiveness, safety and efficiency of the American healthcare system. That means improving outcomes for everyone:  patients, providers and payers.  

It's a holistic approach that overcomes the obstacles to achieving care coordination, including disjointed and varying processes that current prevail among and between primary care sites and specialty sites. This leaves patients and caregivers often unclear about why they are being referred from primary care to a specialist, how to make appointments and what to do after seeing a specialist. Transitions in care often result in lost information and inefficiencies.

Palliative care offers personalized support to streamline these “bumps in the road,” aligning physicians and other care teams to organize patient care activities, and creating seamless transitions in care that directly achieve safer, more effective care. Palliative clinicians are experts at identifying patient's needs and preferences to ensure that this information is known ahead of time and communicated at the right time to the right people.

Looking ahead…

As the healthcare industry searches for greater understanding on how to scale, deliver and pay for services for a health plan population of patients with serious illnesses, a robust PHM solution will be most valuable. The secret to delivering the triple aim lies in proactively identifying high-opportunity patients through predictive analytics coupled with community-based palliative interventions that improve care outcomes and experience.    

A vast frontier for PHM sets the stage for new collaboration and innovative models of care, with opportunities to engage fresh approaches that can tackle some of the most profound challenges facing patients, families and society.   

Terri Maxwell is the chief clinical officer at Turn-Key Health.


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