Population Health Management OverviewWhat Does It Mean for Me and My Patients?
21st Annual Preparing Health Professionals for the 21st Century
Conference
March 13-14, 2015
Griffin Gate Marriott Lexington, KY
An Equal Opportunity University

Acknowledgements
Presenter:
Roberto Cardarelli, DO, MPH
Professor and Chief of Community Medicine, UK
College of Medicine
UK Division of Community Medicine:
Jennifer Schilling, MPH
Kentucky Ambulatory Networker Coordinator
An Equal Opportunity University

Needs Statement
• Healthcare changes are impacting the way we
deliver care with a focus of managing
populations, and not mere individuals, to
improve the care that is delivered at lower
healthcare costs. Population Health
Management is a set of skills and processes
that will assist us in these efforts.
Presentation Objectives and Outcome
Objective 1.1: Understands why population health management
(PHM) was developed and its role in ACA reform.
Objective 1.2: Identifies the key components of PHM.
Objective 1.3: Identifies the overarching process of implementing
PHM in their clinical unit.
Outcome/Competency: The clinician reliably disseminates
information about the importance of and how population health
management is integrated in ACA reform to their clinical unit.
An Equal Opportunity University

Why Population Health Management?
Population Health Management’s role in the Affordable Care Act
“Simply put, in the absence of a radical shift towards prevention and public health, we will
not be successful in containing medical costs or improving the health of the American people”
~ President Barak Obama
Social
Setting
Individual
Social
Ecology
Model of
Health
Family
An Equal Opportunity University

Community
Why Population Health Management?
IHI’s Triple Aim
Population Health
Triple
Aim
Per Capita Cost
An Equal Opportunity University

Experience of Care
Why Population Health Management?
Current vs. Future Financial Incentives as PHM Drivers:
Volume-Based (Fee-for-Service) Reimbursement
(Current model)
Risk-Based Reimbursement
(Future model)
Low financial accountability for cost of care
High financial accountability for cost of care
Population: patients who present at the
doctor’s office
Population: every patient in the provider
organization panel, regardless of whether
they present at the doctor’s office
Infrastructure (technology, data, staff, etc.)
needed to manage more than the sick/most
complex patients is minimal
Infrastructure must exist to manage the entire
population
Volume and operational efficiency are valued
and rewarded
Optimization of cost and quality are valued
and rewarded
An Equal Opportunity University

Why Population Health Management?
How to be a Population Health Leader through high-impact
behaviors:
Person
Centeredness
Front-Line
Engagement
Relentless
Focus
Transparency
No
Boundaries
An Equal Opportunity University

Assessment
Which of the following is not one of the Institute for
Healthcare Improvement’s Triple Aims:
A)Reducing the per capita cost of health care
B) Improving the health of populations
C) Providing health insurance coverage for > 80% of the
U.S. population
D)Improving the patient experience of care, including
quality and satisfaction
An Equal Opportunity University

Assessment
Which of the following is not one of the Institute for
Healthcare Improvement’s Triple Aims:
A)Reducing the per capita cost of health care
B) Improving the health of populations
C) Providing health insurance coverage for > 80% of the
U.S. population
D)Improving the patient experience of care, including
quality and satisfaction
An Equal Opportunity University

Assessment
Population Health Management is only focused on
patient populations that are engaged in a clinical
setting:
A)
B)
An Equal Opportunity University

True
False
Assessment
Population Health Management is only focused on
patient populations that are engaged in a clinical
setting:
A)
B)
An Equal Opportunity University

True
False
Key Components of Population Health Management
Conceptual Framework
Population Monitoring/ Identification
Health Assessment
Risk Stratification
Low
risk
High
risk
Health Continuum
Patient Centered Interventions
Health Promotion,
Wellness
Health Risk
Management
Care Coordination
Advocacy
Disease/Care
Management
Community Resources
Patient
Organizational
Interventions(culture/
Environment)
Tailored Interventions
Operational Measures
Impact Evaluation Outcomes
Behavior
Change
Psychosocial
Outcomes
An Equal Opportunity University

Financial
Outcomes
Clinical and
Health Status
Patient and
Provider
Productivity,
Satisfaction, QOL
Key Components of Population Health Management
Population Monitoring/ Identification
• Organizations use administrative data to push updated “population list” to
clinicians
• Clinicians and teams become aware of all patients in their population
• Patients link themselves to medical homes and organizations
Patient Population
Clinic/ Group Patient
Empanelment :
Provider 1
An Equal Opportunity University

Provider 2
Provider 3
Patient 1
Patient 1
Patient 1
Patient 2
Patient 2
Patient 2
Patient 3
Patient 3
Patient 3
Key Components of Population Health Management
Repeat measurement process over time
Health Assessment
Laboratory,
pharmacy,
clinician
documented
information
Health
Insurance
claims
Self reported
questionnaires
Combine and Analyze
Make Changes Accordingly
An Equal Opportunity University

Key Components of Population Health Management
Risk Stratification
• Represent the continuum of care
• Aids organizations and clinicians to focus resources
appropriately
Healthy
An Equal Opportunity University

Health/Emotional
Risk
Chronic Illness
End of Life
Key Components of Population Health Management
Enrollment/ Engagement
• Help patients access care and interventions appropriately
• Clinicians offer patient-specific care plans and interventions based
on the individual patients needs, preferences, activation, values,
and capabilities
• Patients participate in developing their customized care plan
An Equal Opportunity University

Key Components of Population Health Management
Patient-Centered Interventions
• Communication and Intervention Delivery Modalities
• Organizational Interventions (Culture/ Environment)
• Tailored Interventions
•
•
•
•
Health Promotion
Health Risk Management
Care Coordinator/ Advocacy
Disease Case Management
An Equal Opportunity University

Key Components of Population Health Management
Impact Evaluation (Program Outcomes)
Operational
Measures
Health Status &
Clinical Outcomes
Psychosocial Drivers
Health Behaviors
SelfManagement
Compliance
Service
Utilization
Productivity
Satisfaction
of Patient &
Provider
Quality of
Life
Financial Outcomes
An Equal Opportunity University

The Quality Improvement Process
Population Identification
Health Assessment
Risk Stratification
Enrollment/ Engagement
Patient- Centered
Interventions
Impact Evaluation
(Program Outcomes)
An Equal Opportunity University

Population Health Management Aims
PHM Component
Patient Population Identification
(Empanelment)
Organization
Clinical Team
Patient
Clinical teams receive updated
population lists via administrative
data
Awareness of all patients in their panel
Linkage of individuals to health
organization and medical home
Health Assessment
Demographics, values, and special
needs of the customer are assessed
Validated tools are used to assess patients:
health risks, preferences, values, and
activation within their patient panel
Increased awareness and understanding
of personal health risks and conditions
Risk Stratification
Identifies and prioritizes at-risk
patients for clinical teams; Offers
tailored interventions for identified atrisk population segments
Decrease acute and chronic health risks by
prioritizing at-risk patients and intervening
by offering appropriate patient support
and programs
Understanding of one’s condition
severity, and how personal behaviors
affect risks and conditions
Engagement
Support patient engagement; Aids
patients with their access to care and
interventions
Tailored care plans and interventions are
offered based on patients’ needs,
preferences, values, capabilities, and
activation
Participation in developing their own care
plan; Become active in their care with
information and support tools they
receive
Patient Centered Interventions
Resources allocated towards areas of
greatest population risk, and health
improvement opportunities
Provides at-risk patients timely care and
access to helpful acute and chronic health
care resources
Gain knowledge regarding self-care plan
implementation for
improvement/stabilization of health
Impact Evaluation
Understanding and improvement of
population health interventions
impact
Identification of areas for care
improvement
Improved control of health conditions
An Equal Opportunity University

Population Health Best Practice Framework
Implementation Levels
PHM Best Practice Level
V
IV
III
II
I
Patient Population ID
(Empanelment)
Health Assessment
Risk Stratification
Engagement
Patient-Centered
Interventions
Impact Evaluation
At point of care, clinical
team receives up-to-date
patient / patient panel
specific data
Clinical team is
automatically notified of
new / conflicting info that
requires a resolution
Stratification of patients
and populations across all
clinical teams are
automatically generated
via a valid tool; gaps are
flagged
Clinical team monitors,
optimizes care plan, and
care team across all
settings; Medical Home
A clinician/ patient
collaborative care plan exists;
Primary, Secondary, and
Tertiary prevention-focused
Up-to-date feedback;
Outcomes are met or
exceeded based on patient,
peer, and population goals
Patient information (ID,
health risks, condition
controls) is available from
all clinical team members
Clinical team receives
information regarding
patients: health, values,
and preferences
Stratification lists based
on: claims, labs,
screenings, and health
assessments are available
Clinical team
coordinates across
connected settings and
engages with patients in
the “medical home”
Clinical team is aware of a
responsive to patient needs
and preferences; Primary,
Secondary, and Tertiary
prevention-focused
Clinical team receives
patient outcomes
information; Peer
organization sets
performance goals
Clinical team registry
exists, containing: key
diagnoses, tests, medical
histories, condition
controls
Clinical team maintains a
patient list with diagnoses
Patient health risks are
evaluated on year-to-year
comparisons of
assessments
New health risks are
identified via registry lists
and health assessments
Clinical team focuses on
previous and new risks
to engage with patient
Primary, Secondary, and
Tertiary prevention-focused;
Risks-strategies are identified
Clinical team is unaware of
patient outcomes unless
they are directly involved in
the patients care
Baseline health described
by patient; patient
assessed during visit
Risk based on clinical
team lists with diagnoses
and patients frequency of
appointments
Clinical team engages
with patient during
appointment
Known health risks and
current patient need drives
interventions
Clinical team is unaware of
patient outcomes unless
they are directly involved in
the patients care
Clinical team ID’s patients
through direct interaction
and records on paper
Clinical team assesses
patient during visit
Clinical team is aware of
high risk patients based
on patients frequency of
appointments
Clinical team engages
with patient during
appointment
Known health risks and
current patient need drives
interventions
Clinical team is unaware of
patient outcomes unless
they are directly involved in
the patients care
An Equal Opportunity University

Assessment
Which of the following are components of
the Population Health Management
conceptual framework?
A)
B)
C)
D)
E)
An Equal Opportunity University

Population Identification
Risk Stratification
Impact Evaluation
(A) and (B)
All of the above
Assessment
Which of the following are components of
the Population Health Management
conceptual framework?
A)
B)
C)
D)
E)
An Equal Opportunity University

Population Identification
Risk Stratification
Impact Evaluation
(A) and (B)
All of the above
Assessment
The process of empanelment includes:
A) Obtaining patient list from billing data,
EHR, and insurance
B) Grouping patients by their risk level
C) Assigning patients to a provider and/or
team
D) (A) and (B)
E) (A) and (C)
An Equal Opportunity University

Assessment
The process of empanelment includes:
A) Obtaining patient list from billing data,
EHR, and insurance
B) Grouping patients by their risk level
C) Assigning patients to a provider and/or
team
D) (A) and (B)
E) (A) and (C)
An Equal Opportunity University

Assessment
Health Assessment and Risk Stratification are the
same key Population Health Management
component.
A) True
B) False
An Equal Opportunity University

Assessment
Health Assessment and Risk Stratification are the
same key Population Health Management
component.
A) True
B) False
An Equal Opportunity University