Population health management (PHM) broadly refers to the proactive application of interventions and strategies aimed at promoting good health outcomes among a specific group of people at the lowest possible cost. PHM remains one of the most critical focus points of modern healthcare management and an essential driver of value-based care.
PHM is growing in significance with the paradigm shift in resource allocation in hospitals and reimbursement strategies. More hospital resources are being channeled to outpatient care to clamp down on readmissions, and reimbursements are also becoming more performance-based, driving innovations in population health management.
However, many PHM systems are flawed by their treatment of populations as a homogenous group rather than a collection of heterogeneous units. Patients typically present to hospitals when they develop an acute condition or complications of chronic disease, or when they desire some form of health screening, and healthcare professionals provide the needed care.
However, health is a multifactorial entity and requires a multifaceted approach, and knowledge of this and provision of a continuum of care, which involves bearing accountability for the overall health of a group of people beyond treatment of present health complaints defines population health management.
PHM strategies consider the socioeconomic, environmental, genetic and behavioral factors that affect the overall health of a spectrum of people. Additionally, population health management strategies not only offers continuous and personalized value-based healthcare across a stratified population of patients, but it also reduces the cost of health plans, relieving providers and payers some financial burden by promoting preventive care and lowering complication rates.
Components of and Strategies for Population Health Management
At the core of PHM strategies are essential components, around which healthcare can be redefined to meet the patient’s needs and promote better outcomes. These components include;
- Clinical care
- Patient and Provider Engagement
- Healthcare tech initiatives
- Clinician engagement and care coordination.
- Community services
A comprehensive evaluation of these components, for every healthcare provider or organization, helps to identify areas of strength and areas of weaknesses, creating goals for each to promote better health care for patients.
Clinical Care
Provision of adequate health care is at the center of PHM programs and is the essential component. Building strategies for effective clinical care delivery should focus on the overall health of the person and not just the presenting illness. Therefore, this requires a coordinated team of skilled providers knowledgeable in wellness, preventive medicine, diagnostics and therapeutics, appropriate follow-up care, and end-of-life care.
An important aspect of clinical care strategies is the provision of a patient-centered care factoring in social and environmental indicators including distance from home and availability and level of support for each patient. This facilitates the provision of continuous health care for patients in centers close to their homes.
Patient risk stratification goes beyond demographics to the pattern of care needed and medical conditions in determining the healthcare needs and offering appropriate medical interventions.
Providers need to set up quality follow-up care to continue to deliver healthcare even after the patient has left the hospital. Adequate follow-up care involves the use of efficient patient monitoring systems such as engaging patients through web portals and email messaging. In addition, instituting proper follow-up care reduces the risk of complications, cutting down hospital readmissions and reducing healthcare costs ultimately.
Another crucial part of clinical care to be incorporated into PHM strategies is medication compliance. Medication nonadherence could be costly in the long-run and detrimental to patient health. Reports note that noncompliance with medications costs employers about $8 million per 100,000 lives on health insurance plans.
Strategies to promote patient compliance with medications include simplifying the means of getting medications and instituting proper follow-up with patients during the course of the treatment. One example that offers a potential solution, as noted in a report in 2016, is home delivery meds.
In this study, it was revealed that picking up prescriptions from pharmacies was associated with a 47 percent compliance rate, while patients who have their medications delivered to them at home were complaint with these drug treatments 74 percent of the time.
Furthermore, in a recent study published in the American Journal of Managed Care (AJMC), researchers found that EHR and pharmacy records are helping providers track patient compliance to medications to help stratify patients and target those who would need medication non-compliance solutions.
Patient and Provider Engagement
Patient and provider engagement plays a vital role in PHM. Patients, as well their healthcare providers, constitute the main factors that influence patient health. As noted earlier, effective patient-provider engagement builds strong relationships which can improve health outcomes and treatment compliance, ultimately reducing costs.
Patients want to be actively participating in their healthcare, in the decision-making process for determining a care plan appropriate for their health needs. Effective PHM programs require strategies for continuous engagement with patients at all life stages – from childhood to old age – and engagement should be done in patterns based on individual preferences, for example, through email or video messaging and online patient forums.
Identifying how patients wish to engage is key to creating appropriate measures and technological initiatives to connect effectively with patients and provide adequate support. This ensures timely flow of necessary information between patients and providers.
These engagement strategies are also fundamental in addressing treatment nonadherence by providing treatment dispensers, for example, and appropriate follow-up support. Engagement strategies involve patient-centered education which assesses each patient’s cognitive capacity to understand their health needs and also to help patients create appropriate healthcare goals. This requires a careful interaction with patients to gain insight into their knowledge of their care plan and how it could be properly followed.
Healthcare Tech Initiatives
Technological advances in healthcare should be incorporated into PHM programs to improve health outcomes. Essentially, patient-centered technologies, such as the use of smartphone apps and telehealth services, as part of PHM strategies enhance patient engagement and participation in their healthcare plans, meeting the needs of specific patient groups across various geographical regions, and bypassing the barriers caused by distance.
Telemedicine is an effective technological tool enabling interactions between patients and healthcare providers in real time, with a wider patient reach particularly, those who have poor access to health care.
Telehealth software and apps include bi-directional audiovisual functions that allow free flow of clinically relevant data between patients and providers, also giving both parties access to a remote team of healthcare professionals.
Furthermore, telehealth platforms provide a more expansive way of coordinating the healthcare continuum particularly for patients with chronic medical conditions and for facilitating targeted healthcare to meet the needs of various patient groups.
In a Canadian study published last year, it was reported that telemedicine was used to provide image and text-based orthopedic consultations for 1,000 patients who suffered mild-to-moderately severe fractures, bypassing barriers of distance and saving these patients the difficulty in traveling miles to a hospital for an orthopedic review.
Clinician Engagement and Coordinated Care
Effective PHM programs require access to health care professionals from a wide array of specialties and with varying expertise and skills. This ensures a network of highly skilled healthcare providers offering a well-organized and integrated care to patients. This team-oriented approach is a key driver for good healthcare outcomes.
Constant interaction between members of a healthcare team provides a more targeted approach to providing care, eliminating redundant investigations and repeated procedures, in turn lowering healthcare expenditure.
According to a report by the Healthcare Information and Management Systems Society (HIMSS), patient engagement includes four components including patient education, engagement, preventive initiatives, and population health control.
Furthermore, physician acquisition strategies should be tailored to meet health needs of the population being served. A careful evaluation should be done on the target population, assessing health needs and gaps in healthcare delivery to determine the required network of professionals.
For example, in a region with high rates of diabetes, a healthcare organization requires the acquisition of and a good network of endocrinologists, dieticians, and other healthcare personnel who have received training in diabetes care.
Community Services
Community or social services play a huge role in population health management, being a key component of preventive care which reduces healthcare spending and leads to better health outcomes.
Community services involve first understanding the basic needs of members of a community which influence their health. Some of these include financial issues, nutritional problems, and a poor access to good healthcare systems.
For instance, addressing nutritional needs of a community in no small way contributes significantly to better health outcomes within a community and is a key part of PHM programs. For example, in a population with high incidence rates of obesity and cardiovascular complications, key strategies include improving access to and providing technical and financial assistance to affordable healthy food and beverage outlets and fitness and wellness centers for physical activity.
Additionally, providing financial assistance to seniors who may not be able to afford prescriptions goes a long way in promoting better health for the aged.
Essentially, population health is a multifaceted entity which requires a multidimensional approach. These strategies constitute the key components of an effective population health management program and remain essential cost-effective ways of promoting better healthcare for various patient groups in a community.
