Population Health Management

6/23/2014
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http://www.healthcatalyst.com/Population-Health-Management-Outcomes
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http://www.healthcatalyst.com/wp-content/uploads/2013/07/Brent-From-Care-Management-to-Population-
Health-Management-FINAL.pdf
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http://www.healthcatalyst.com/population-health/
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http://www.insigniahealth.com/solutions/patient-activation-measure
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http://ihealthtran.com/pdf/PHMReport.pdf
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http://cmcd.sph.umich.edu/what-is-chronic-disease.html
Population Health Management

1. What is it?
Kindig and Stoddard (2003), define population health as an approach *that+ focuses on
interrelated conditions and factors that influence the health of populations over the life
course, identifies systematic variations in their patterns of occurrence, and applies the
resulting knowledge to develop and implement policies and actions to improve the
health and well-being of those populations
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2. How did this concept originate?
Used to be care management (payer-based) problems with this approach
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:
a. Healthcare data (claims) are typically retrospective in nature, 1-3 months
delayed
b. Data does not universally include the actual clinical info required for critical
insight, makes a series of assumptions about patients
c. Big gains from this approach have plateaued
Change to population health management (driven by providers)
3. How are hospitals implementing PHM?
Providers need a population health management solution with extensive rules that will
identify their at-risk populations, capture all known patient data from any possible
sources, coordinate care, and engage patients directly in their own care
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Sources of data: Electronic Medical Record (EMR) and Health information exchange
(HIE) vendors have amassed real-time clinical data by connecting disparate doctors,
hospitals, pharmacies and labs. Integrating this data with retrospective claims data gives
a rich picture of patients or members health use data to create a PHM system
4. Health Catalyst (HC) PHM System example:
3 systems needed for effective PHM
3
:
a. Clinical best practices: content system - In order to improve care and reduce
costs, any population health initiative needs to understand what evidence and
expert consensus exist about care best practices and waste reduction
opportunities. Most studies show that it can take years to systematically
integrate new knowledge and best practices into a standard process of care,
need quicker
b. Data warehouse and analytics: measurement system - You need data across
the entire continuum of care in order to manage patient populations. This
requires an enterprise data warehouse (EDW) platform. An EDW is the
central platform upon which you can build a scalable analytics approach to
systematically integrate and make sense of the data.
c. Organizational: deployment system - Once a population health initiative is
able to effectively collect and use prioritized data, leaders must organize
permanent teams which span facilities, traditional departments, and
acute/ambulatory boundaries, and integrate technical and clinical personnel
across the care continuum in order to sustain their gains
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HC provides the following for each system needed:

Further implementation:
a. To promote patient engagement and gauge the extent to which these
chronically ill patients feel empowered to self-manage their health and
participate in the decision-making process, clinical leaders championed the
integration of a metric known as the Patient Activation Measure, or PAM score,
into the EDW
b. This assessment evaluates a patients knowledge, skills and confidence level
with regard to managing his or her health

HC has developed a
range of products,
applications, and
services that span the
different stages and
levels of the Analytic
Adoption Model. No
matter where a system
has progressed in
analytics, there is a set
of products that is
optimized for current
environment and
scalable to meet future
analytics needs;
Installation and
Improvement Services

HC deploys a Late-Binding Data Warehouse that enables
healthcare organizations to automate extraction,
aggregation and integration of clinical, financial,
administrative, patient experience and other relevant data
and apply advanced analytics to organize and measure
clinical, patient safety, cost and patient satisfaction
processes and outcomes
HC Advanced
Applications provide
insights into evidence-
based metrics that
support multi-
disciplinary teams in
driving for care
improvements that
result in measurable
improvement in quality,
outcomes, patient
safety, and waste
reduction. Modules
span the continuum of
clinical management of
populations and clinical
workflows, patient
injury prevention, and
department operations

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5. Patient Activation Measure (PAM) segments consumers into 1 of 4 progressively higher
activation levels; PAM score can also predict healthcare outcomes including medication
adherence, ER utilization & hospitalization
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:

PAM scores reveal activation models (specific ex. Insignias health activation model,
which today supports over 60 organizations and their medication adherence, disease
management, medical home, wellness promotion and care transition programs)
Hundreds of consumer health characteristics have been mapped to patient activation
levels across more than two dozen health conditions, as well as disease prevention and
health promotion
As activation gains, individuals become significantly:
i. More adherent to medications
ii. More likely to eat healthier and engage in physical activity
iii. More present in the workforce and more satisfied in the jobs
iv. Less likely to use the ER or to be readmitted post discharge
v. More engaged with their clinicians

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Scope of PAM:

6. Effective PHM:
Requires motivating and collaborating with patients to help them take care of
themselves most powerful motivator is the patient-physician relationship
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Interplay between human interventions and automation tools automated messaging
to all discharged patients can urge them to see their providers, fill their prescriptions,
and call the hospital if they have any questions about their care plan
When patients get recommended screening tests, they are more likely to be aware of
their health issues and do something about them
Newer technologies also have great promise ex. home telehealth devices, which have
cut hospital admissions by 19% and hospital bed days, by 25%, for the patients involved,
and can reduce mortality in patients with chronic diseases
Practices can also use technology to collect and integrate patient-reported info and
activities, such as Health Risk Assessments, blood pressure tracking and medication
adherence, for more timely risk management and coaching

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7. Other marketing efforts/implementations of a healthy lifestyle examples:
Aegis Health Group OneCommunity Population Health Portal: custom-branded,
population health portal that puts actionable health information at consumers
fingertips through an easy-to-use and engaging website
CDCs effort: Vaccines for Children Program (VFC) helps provide vaccines to children
whose parents or guardians may not be able to afford them, protects any child under
the age of 19 from 16 different diseases; nationwide, there are over 44,000 doctors
enrolled in the VFC Program
Nurse Advice Lines (NALs): [the better] algorithmic approach of asking a series of
questions that enables a nurse to get to a deep level of detail to identify the exact
problem and determine the best solution; have the ability to accurately and
appropriately redirect patients from unnecessary ER room visits to other forms of care
that effectively treat the medical issue; educate patients on self-care and healthier
lifestyle choices

EXAMPLE WEBINAR:
http://www.healthcatalyst.com/webinar/population-health-fundamentals/

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Chronic Disease Management
1. What is it?
Helping patients control the effects of their chronic illness
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When designs for patient education, service delivery and payment systems all focus on
supporting patients efforts and building the capacity of individuals and families to
manage disease effectively, disease control increases, health care costs go down, and
family well-being improves
2. Implementation examples:
Administration on Aging (AoA)s Empowering Older Adults and Adults with Disabilities
through Chronic Disease Self-Management Education Programs (CDSME):
a. Programs provide older adults and adults with disabilities with education and
tools to help them better manage chronic conditions
b. In 2012, 22 states were funded for this program; as of March 2013, the
CDSME grantees had hosted a total of 800 workshops and provided
workshops to almost 9,000 participants in the first six months of their
cooperative agreements
c. Most common conditions among the participants are hypertension (44%),
arthritis (41%) and diabetes (31%); average age of participant is 66 years
McKesson offers Disease and Chronic Condition Management a combination of nurse-
directed activities and technology-driven tools that offers personalized interventions to
help manage the total person, seamless co-morbidity management and counseling from
registered nurses, and regular communication with a members physicians
Administration for Community Living (ACL)s Center for Disability and Aging Policy
(CDAP)/No Wrong Door Program (NWP):
a. Systems are designed to serve as highly visible and trusted places available in
every community across the country where people of all ages, incomes and
disabilities go to get information and one-on-one person-centered counseling
on the full range of long-term services and support (LTSS) options
The Center for Managing Chronic Disease has taken global action through their
International Projects in China, Australia, England and Scotland:
a. China for ten years, the Center has worked in collaboration with the Beijing
Heart, Lung and Blood Vessel Institute, Capital Institute of Pediatrics, and the
Tianjin Center for Disease Control and Prevention to make available to children
in China a proven program for enhancing asthma outcomes
b. Australia an Australian peer teaching program for school students with
asthma, Triple A, is being adapted and assessed in 19 middle schools in Detroit,
Michigan, colleagues from the Department of Public Health and Community
Medicine at Westmead Hospital in Australia are collaborating in this effort; the
Physician Asthma Care Training Program (PACE) is being tested in Sydney with
local health care providers
c. England and Scotland colleagues in London and Aberdeen are examining, in
two separate studies, the effect the PACE program has on patients in these
countries; they are enrolling health care providers and following patients over
time to ascertain changes in asthma control
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