Led by a range of Medicare pilot programs emanating from the “Patient Protection and Affordable Care Act” (ACA), providers are being held responsible for the health status of a defined population instead of just those who see a clinician or go to a hospital. This step up to population- level health involves identifying the people in a community who need attention and giving it to them.
Trustee magazine interviewed experts on population health as well as health system executives that took a population-based and community-focused approach a number of years ago. Their advice and observations are distilled into a list of 10 things trustees should know about population health.
1. This is not voluntary. Accountability for the health status of a population is where we’re headed.
Hospitals already are on the hook to prevent discharged patients with certain diagnoses from having to be readmitted within 30 days, notes David Nash, M.D., dean of the Jefferson School of Population Health in Philadelphia. “That’s all about practicing effective population health to prevent a readmission,” he says. The ACA’s experiments in accountable care organizations and other value-based, outcome-oriented models of health improvement are pilots now, but suggest the paths the government will take.
2. Trustees have to think outside the four walls of the institution.
In the new era, hospitals and physician offices become way stations in the larger health management of “covered lives,” which will take the place of “patients” as the main focus of a health system’s activities.
“That calls for all kinds of services not currently offered: for example, maybe it’s of value for a hospital to support a local senior center – put some physicians and nurses, case managers into that center to decrease unnecessary admissions, reduce readmissions,” Nash says.
3. Promoting the good health of the community has to become more than a nice mission statement; trustees need a keen understanding of how to do it.
Nash says a first step may be the outward moves required to extend the hospital’s reach past its usual terminus of responsibility at discharge: a nurse call center to contact people recently discharged, a case manager to visit patients at home and make sure they return for follow-up appointments.
Good health also involves helping clinicians do more for patients than current care settings can accomplish, says Donald Caruso, M.D., medical director at Cheshire Medical Center/Dartmouth-Hitchcock in Keene, NH. “The biggest battle that I’ve had is on the ground, in the exam room, getting people to change lifestyle and do the things that actually impact their health outcomes,” he says.
4. Boards have to re-engineer their strategic priorities from the ground up to make population health a central theme, reallocate resources and commit to the changes.
“Boards are going to have to think about how we go upstream,” says AHA Chairman-elect Benjamin Chu, M.D., group president of Kaiser Permanente’s Southern California Region and Hawaii. It goes to the heart of what a nonprofit hospital should do to demonstrate community benefit. Typically, profits are plowed into medical education and expanding services, he says, “but a portion maybe should be devoted to thinking about what would make a bigger impact on communities overall.”
5. The ability to identify and track target populations, then analyze preventive and interventional needs, is the foundation of population health.
“You can only have an impact on the health of a larger community over time if you have good information about their characteristics – what are their health habits, what are their chronic conditions, how often do they participate in preventive health measures and screening programs that can identify conditions early enough so that you can intervene and prevent the more extreme things from happening?” Chu says.
“We can actually do that with a digital or electronic record and population- management tool. We can in this day and age track the relative health of our population over time.”
At Kaiser, Chu can tell the characteristics of 625,000 covered lives in Southern California, which are available not just to doctors, but also any authorized caregiver who comes into contact with someone in person, on the phone or by email.
That’s how it has been able to control the hypertension symptoms in 87% of the people so diagnosed, as well as make big strides in other paths of health improvement.
6. Physician leadership development is a smart investment.
The clinical vehicle for executing accountable care is a closely cooperating contingent of health professionals formulated to personalize care for people before, during and after their visits to the physical office setting.
Called a patient-centered medical or health home, the team is led by a primary care physician and can include physician assistants, nurse practitioners, a behavioral therapist, and health coaches for diet, exercise and lifestyle changes. Given that “the role of physician development is absolutely critical, physician leadership will make or break an accountable care organization,” says Barbara Gray, Premier Inc’s vice president of accountable care collaboratives.
7. Hospitals not only have to find the people in greatest need, but also leverage a community’s resources to reach and support people where they live.
Local health departments, schools and other community resources likely are helping to keep their constituents healthy as part of their roles, says Michael Bilton, executive director of the Association for Community Health Improvement, an AHA personal membership group.
The idea is not to reinvent services and duplicate them, but to find out what’s being done already and strike mutually beneficial agreements.
8. Limited resources have to be put to the most pressing need with the biggest possible impact.
How do you fully serve the needs of all with a limited budget?
Focus on the medical minority that stands out, at least initially.
“There’s a lot of evidence that a relatively small proportion of the population accounts for a disproportionately large share of health care use and health care cost – and suffering through ill health,” Bilton says. It makes sense to “identify those higher-risk or higher-using, less-healthy groups and then deploy a range of population health strategies in service to improving their health, which should help ease the burden on the health care delivery system.”
9. Good programs and value-oriented goals are meaningless without payment that rewards populationlevel health management and its measurable health and cost-containment gains.
Payers should be just as interested as providers in aligning around improving quality outcomes while controlling costs and improving member experience,.
Boards should ask what the role of local payers likely will be – for example, who will be responsible for care management and what the criteria are to evaluate potential payer partners.
10. The health care field as currently constituted has insufficient skills for the challenge.
The need for new expertise may have to start at the board level: for example, representation in the fields of wellness, chronic-illness care, public health, preventive approaches, and notably epidemiology, or the study of the distribution and determinants of all things health-related, including diseases.
Morrissey is a Mount Prospect, IL-based freelance writer. This is an excerpt of an article that first appeared in the July issue of Trustee magazine, wwwtrusteemag.com, an AHA and Health Forum publication.