Five Essential Population Health Management Tips

Posted by Continuum on Dec 6, 2016 10:30:00 AM

Success in VBC initiatives depends on smart pop health strategies

Population Health Management (PHM) is the buzzword of the moment when it comes to success in value-based care initiatives. There’s a good reason for that – done right, PHM has a strong chance of helping providers realize the goals of the triple aim and generate real revenue to reinvest in their organizations.

Don’t let all of the buzz distract you from reality. As we’ve learned from watching Big Data’s hype cycle, it’s important to focus on how you can make PHM work most effectively for you. It’s becoming clear that simply purchasing a PHM solution isn’t the silver bullet that’s going to deliver success.

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Topics: Practice Transformation, Value-Based Healthcare, population health management, PHM

Coordinated Care Best Practices = Successful Outcomes

Posted by Continuum on Apr 27, 2015 2:40:52 PM


The Need for Coordinated Care

The number of Americans with at least one chronic health condition is rising. A Commonweath Fund International Survey found that 23% of patients with a chronic illness saw four or more doctors over the last year and 46% reported taking four or more prescriptions on a regular basis.1 These patients have higher than average healthcare utilization rates, making the management of their care particularly vital, yet complicated. Consequently, a targeted care coordination program is an essential component of any larger Population Health Management initiative.

The successful management of patients with chronic conditions requires care that is well-coordinated between providers, patients, and the care team. The Institute of Medicine has remarked that care coordination “has the potential to improve effectiveness, safety and efficiency of the American health care system”2 and can result in higher survival rates, fewer emergency department visits, and lower medication costs.3 Furthermore, a Health Affairs policy brief found that the lack of coordinated care is costly and created $25 to $45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital admissions.4

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Topics: Coordinated Care, population health management, care coordinators

CINs: Providing Value Through Population Health Management

Posted by Continuum on Feb 27, 2015 11:25:00 AM



The U.S. Department of Health and Human Services (HHS) has set a goal of tying 30% of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50% of payments to these models by the end of 2018, proving that value-based reimbursement is swiftly becoming the norm in today’s healthcare environment.1

However, recent studies show that many of the institutions which were awarded value-based payments this year are now facing government-issued penalties. A recent article in Kaiser Health News reported that 55% of hospitals graded by Medicare on quality––some 1,700––earned higher payments this year for meeting quality metrics. However, fewer than 800 of the 1,700 hospitals that earned bonuses will actually receive extra money because they have been penalized for high hospital readmission rates and hospital acquired infections.2

Payment studies on hospitals, a microcosm of U.S. health care providers, provide useful insight into the pitfalls of value-based purchasing agreements. Moreover, they underscore the importance of understanding what happens to patients outside the hospital in an ambulatory setting. Improving the delivery and value of care requires more than just an electronic health record (EHR) – a robust, integrated healthcare technology infrastructure is critical for a Clinically Integrated Network (CIN) to achieve successful population health management.

Pursuing a population health strategy––the need for robust health technology capabilities

Quality and operational improvements are mandates for functioning CINs. Performance must be measured before it can be improved. The right technology platform is necessary not only to capture the complete picture of clinical and operational performance and form a basis for evaluating physician members, but also to identify patients in need of disease management and intense interventions.4, 5 Without the appropriate technology infrastructure, CINs will have difficulty providing clinical decision-support, reducing variability of care and coordinating care across the network. The right platform is also necessary for the administrative support, scheduling, and practice management needed to maintain a consistent revenue stream for continued network investment.5

Technology interoperability is the challenge

As a result of the recent HHS mandate, most physician groups, independent physician associations (IPA), and hospitals have already invested significant time and financial resources to replace paper-based records with an EHR. However, because not all EHR systems are the same, achieving interoperability across a network is often a challenge. HHS has recently proposed a draft Interoperability Road Map to address the secure exchange and use of electronic health information by both providers and consumers.6 It will, however, be a long time before standards are implemented.

For networks with differing EHR platforms, one solution to the interoperability challenge is to use an EHR-agnostic integrated platform that provides actionable data at the point-of-care. A simple performance dashboard that combines and organizes patient data can be developed to identify clinical gaps in care during a patient encounter and facilitate informed decision-making. Care coordinators are better positioned to intervene and manage a patient population with detailed care plans customized for individual patients and their healthcare needs.

Other dashboards can be developed for practice management reporting purposes. Allowing individual physicians, practice administrators and organizational leadership to track productivity, staffing efficiency, revenue and expenses by physician, site or in total, enables prompt identification of areas of underperformance and the development of concrete improvement strategies to attain performance targets. The ability to combine business intelligence and clinical intelligence is essential to establishing patient registries, improving the quality of care and lowering the overall cost of care.

Disease-based, patient registries are critical to population health management

One of the biggest success factors in transitioning from volume to value is the ability to identify clinically high-risk patients. According to the Medical Expenditure Panel Survey, only 1% of patients were responsible for 20% of health care costs in 2008, and the top 5% of the patient population accounted for nearly 50% of health care costs in 2008 and 2009.7

Proactively managing such clinically high-risk patients is necessary in order to reduce overall costs. A patient or disease registry for specific populations should be established and made accessible to providers across the network. In this way, proactive care and treatment can be delivered to individuals or groups of similar patients, enabling the network to reach quality goals. Patient or population cohort dashboards alert providers of gaps in care or quality measures at the point-of-care. Use of meaningfully-structured EHRs to help track and monitor clinical data across the continuum of services, and an effective ambulatory care strategy, such as the use of centralized care coordinators, can help to identify and engage clinically high-risk patients to keep hospital readmission rates low, for example.

The bottom line

With the appropriate decision-support technology and patient management strategies, a network can thrive in today’s value-based environment. Healthcare technology platforms must go beyond the EHR to improve point-of-care decision-making, improve coordination of patient care, enable implementation of clinical protocols, and track care costs. The ability to document the provision of high quality care at a lower overall cost is key to helping clinically integrated networks negotiate value-based opportunities with payors and employers.

To assist with your strategic planning, download Checklist #3: Does Your Organization Have the Right Tools for Population Health Management? 

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Topics: Value-Based Healthcare, population health management, clinical integration, clincially integrated network, performance metrics, gaps in care, population health tools

The Benefits of Centralized Coordinated Care

Posted by Continuum on Oct 17, 2014 9:01:00 AM

nurse-care-coordinator-on-phone-with-patientCare Coordination Key Component of Triple Aim Success

Healthcare providers have increasingly implemented programs aimed at coordinating patient care across a fragmented healthcare continuum. Although these programs vary widely in structure and style, the primary goals of care coordination programs—to improve disease outcomes while containing overall healthcare costs—tend to be consistent across organizations.1

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Topics: Coordinated Care, population health management, Triple Aim, care coordinators

Unions Adopt New Self-Funded Healthcare Models

Posted by Continuum on Oct 3, 2014 9:41:00 AM


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Topics: Self-Funded Insurance, population health management, Taft-Hartley, ambulatory care, practice management

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