Population health management is a team-based medical approach to managing the care of a specific patient population with similar needs. Factors such as geographical location, ethnicity, medical need, or socioeconomic status determine these groups. Population health focuses on conditions and factors that influence the health of specific populations over their lifetimes, applies this knowledge to develop action plans to improve the health of these populations. 

Population Health is different than Public Health, although the two terms are often confused with each other. The main distinction between the two: Public Health relates to the functions of state and local health departments (like preventing epidemics, containing environmental hazards, and promoting healthy behaviors for the entire population) while Population Health refers to a specific healthcare model that focuses on managing the care of specific groups.

 When effective, population health helps practices reduce the overall cost of care, strengthen financial performance, and enhances the quality of care. 

“Managing Chronic Disease has become a key element of a patient-focused population health program, so looking for practical approaches to chronic care management will be crucial in a value-based healthcare system.”

Why is Population Health Important Today?

Healthcare in the U.S. has been changing from volume-based care to value-based care, which means providers are paid based on patient health outcomes. Population health, like value-based care, is people-focused and centered on increasing access to quality healthcare. It focuses on lowering healthcare costs through more preventative methods and more specialized research. Managing Chronic Disease has become a key element of a patient-focused population health program, so looking for practical approaches to chronic care management will be crucial in a value-based healthcare system, including changing organizational structures. 

Population Health & Chronic Illness

Chronic illnesses are conditions that last one year or more and require ongoing medical attention or limit activities of daily living. The most common chronic diseases are heart disease, cancer, and diabetes. They are the leading causes of death and disability in the U.S and leading cause of the annual healthcare cost, which is now more than $3.3 trillion. 

Chronic illnesses emphasize the importance of population health. People with chronic diseases can be segmented and treated based on their illness, allowing for more thorough data collection and specific services. The number of people living with one or more chronic conditions is projected to grow dramatically as the U.S. population ages overall. Without making changes to our current medical system, Americans will be at greater risk of higher healthcare costs that, in turn, could impact economic growth.

What Are The Benefits Population Health Programs?

Implementing population health programs benefits both providers and patients. These programs enhance care quality by using data to show where care is needed and how to treat populations more effectively. The programs increase provider efficiency by balancing workloads, keeping better track of patient data, and aligning patient data with evidence-based practices. Population health programs also strengthen financial performance by proactively ensuring patients (especially those with chronic disease) receive needed services. 

How Are Population Health Practices Implemented?

To successfully implement population health practices, programs need to use proactive, team-based care, increase outreach, and advanced technology. Effective team-based care involves procedures like clarifying the vision of the program, understanding current data systems, communicating consistently with all members of the team. Programs may need to change and have a better understanding of organizational systems and make sure that management is also on board. 

“In order to successfully implement population health practices, programs need to use proactive, team based care, increase outreach, and to use advanced technology.”

Successful outreach is crucial when using population health practices because it is difficult to target specific population groups without doing detailed outreach work. Outreach involves reaching out to patients that haven’t been in the medical center because they can still be beneficial for collecting data. 

Using advanced technology, like analytics, care coordination tools, and patient health status dashboards, is critical for implementing successful population health practices and allows for more streamlined care coordination across the team.

The Challenges Of Implementing Population Health Programs

Implementing population health programs will come with challenges. The most pressing challenges include:

• increasing documentation requirements
• changing regulatory requirements
• disconnected systems/outdated data
• lack of a central IT platform
• evolving care delivery and payment models
• unmanageable referral administration
• low staffing levels. 

Many of these challenges involve making the transition from fee-based services to more value-based care methods, which is something the entire healthcare industry as a whole is working towards. Making this shift requires providers to adjusts their workflows and communication strategies to be more team-centered.

The shift also involves changing the way providers are reimbursed as well as who can reimburse, because in population health programs the services can be more decentralized (with nurses, behavioral health specialists, and PA’s playing a more significant role). 

Another group of challenges listed above has to do with changing and understanding technology and data systems. To successfully implement population health practices, there needs to be a higher amount of data taken and analyzed, and this data needs to be easily accessible for providers. 

In a recent poll conducted by HIMSS, 67% of organizations practice some form of population management, but only 25% of these institutions have implemented any technology to process population health analytics effectively. It is worth mentioning that over 80% of the polled organizations maintain chronic conditions and wellness services.

How Population Health Management Can Help Practices

One medical center that has proven success using the population health model is the Physicians Medical Center (PMS) in McMinnville, Oregon. PMC successfully used a population health program that changed the way it approached diabetes. PMC has 22 providers, including physicians, behaviorists, pharmacists, nutritionists, and diabetes educators. This team serves 25,000 patients annually. They started their population health program by using a smaller, specified group of 846 patients with diabetes. 

PMC started using a population healthcare model when it accepted the Comprehensive Primary Care Initiative (CPCi), a four-year, multi-payer pilot meant to strengthen their level of care while also incentivizing provider participants. PMC quickly realized that their resources and staff levels were insufficient to support the transition to a population health model, so it made some changes. They got buy-in from providers by presenting them with convincing data that pinpointed the areas requiring intervention. 

Over the course of seven years, PMC administrators made the following organizational changes to meet population health goals:

• Enhance outreach responsibility for patients who are past due for services
• Assign every patient to a primary care provider
• Hire an extended care management team
• Stratify patients based on risk levels
• Create care plans for high-risk and rising-risk patients
• Manage transitional care services for patients discharged from the ED or hospital
• Implement new workflows and a team-based care model
• Share decision-making with patients
• Institute a patient/family advisory council

Population Health & athenaPractice

PMC also used Quatris Healthco’s athenaPractice Solution to gain data from the practice’s electronic medical records for population health. The staff used Quatris Healthco’s system to combine patient records with treatment guidelines to create a comprehensive patient profile. This increase in automation helped the providers spend less time on paperwork and increased their level of care for patients. 

In a six-month population health pilot of 846 diabetes patients, PMC achieved the following outcomes:

• Doubled utilization of diabetes educators from 27 percent to 54 percent
• Reduced the number of patients with A1C higher than 9% by 30%, from 23% to 16%
• Decreased the number of patients past due for office visits or labs by 33% from 45% to 30%
• Rolled out the population health program to the remaining diabetes patients
• Added a retinal eye exam at the point of care

PMC, with the assistance of Quatris Healthco, demonstrated that with the right tools, data, and management, population health models can be successful and increase the quality of services for people with chronic illnesses.