Population Health Management: Methodology

Population health is a growing topic in health care, especially with the increasing pressure to reduce the overall cost of care among the population. Managing your patient populations is critical to improving the total costs of care as studies have shown. In 2013, a study has shown that wellness care reduced the cost of health care by $60.65 per participant, and chronic disease management saved $214.66 per participant. Additionally, CMS will allow reimbursement $42.60 per qualified patient per month using CPT code 99490.

Many healthcare organizations are launching their own population health management programs to take advantage of these savings. I recently wrote an article on a personal experience that shows why managing chronic illness is important. Now I’m going to show you how to take advantage of these healthcare cost savings for your organization. This article is a systematic guide for implementing a population health program using diabetes as a specific project example.

Steps to Success:

1. Information Gathering
2. Design, Validation, Build, & Results
3. Project Planning

Information Gathering

What defines your population?

“All patients that receive care at our facility” might be a good definition for a wellness plan. However, sticking only to this population group, your organization might miss some of the more powerful features of implementing a comprehensive population health program.

While all care is individual, patients can be lumped together into equivalence classes known as disease cohorts. Some examples of this could be “all patients with severe allergies”, or “patients who have an active cancer and are being treated using cytarabine in a home health setting”. More granularly, your team could target all biopsies done by a dermatology clinic – the registry being active per-biopsy instead of per-patient.

Patients in a disease cohort have similar needs and can be compared to each other more easily. In our example, we’ll pick “All patients given a diagnosis of diabetes that is linked to the SNOMED concept diabetes mellitus”. This will allow us to capture all patients within our health system regardless of who did the diagnosis, or what the specific ICD-10 code was.

Having defined your population, it is necessary to include subject matter experts (SMEs) in the design and validation of your project. Usually this is a physician specialist who actively treats the disease experienced by the patient. In the case of diabetes, we’ll have an endocrinologist as the subject matter expert. Ideally this endocrinologist is comfortable with technology and excited to manage their patient populations.

Design, Validation, Build, & Results

A comprehensive population management program for a single chronic disease includes several parts:

1. Measures to gauge if a patient is managing their chronic disease well
2. Registry of the entire target population
3. Defined charts to visualize the status of the population
4. Quality improvement goals based on the metrics
5. Designs of tools necessary to move the status above the goal line

The key role of your SME is to define the metrics that defines if a patient is managing their chronic disease well. In the case of diabetes; intermediate outcomes for A1C, BP, and LDL are strongly linked to health outcomes for the population. These measures, along with other general health indicators like “Last Flu Vaccine Date”, are pulled into a complete registry report.

Your team can now build a registry of all patients fitting the criteria using the definition of the population and the measures identified by your SME. This registry of patients is a finite list that can be managed to provide individualized care. The report can be prioritized to address patients who are in a more critical condition. This includes all patient outreach activities, bulk orders, etc.

The second use of this registry is as the data source for visualizing the current departmental quality. To determine how well your organization is managing the chronic diseases of its patient population, further steps need to be taken. Your EHR is not equipped to view entire populations by itself. Using a Business Intelligence (BI) tool, like Crystal Reports, is critical to determining the current departmental quality and seeing how workflow and tools changes modify the population over time. Without a BI tool, Excel and Access could work.

Following this step in our diabetes example: we could pick average number of patients who are managing their disease well as one of our metrics. Our definition would be “percent of patients who have a current (<30 days old) A1C lab result of <7%”. Each month we’d plot what percent of patients have reached this goal in our BI tool, and then watch it trend over time. This represents one of the measures – and we can weight and combine these measures to create an overall quality status for the department. Note, part of this report definition is also nominating a point person, like the department manager or department head who is responsible for monitoring these reports and meeting goals.

Everything is in place to create departmental quality goals with the reports defined and the registries identified. Philosophy of goals; how aggressive they are, and accountability will vary from one organization to another. Regardless of how your organization approaches goals, these goals should be SMART goals.

One goal for diabetes quality management could be: “97% of our patients will have an A1C lab result within three months if their most recent result was A1C >8% by October 2017.” As the quality of a department improves, these goals will change.

With the goals in mind we can now develop tools for moving the quality bar. This is where the real creativity comes in. Even within disease cohorts these tools will be different from one organization to another. Each of these programs use a combination of operational, workflow, behavioral, and health record system changes. A key benefit of having the BI charts in place is that when we introduce a new change, we can monitor its effect over time. Changes without effect should be reversed or discontinued while modifications with large improvements can be reproduced with other disease cohorts. Some examples at a high level are:

1. Bulk Ordering based on measures
2. Patient Outreach & Engagement
3. Clinical Decision Support
4. Communication through patient portals

Project Planning

Using Scrum project methodology, my population health projects at client sites run in 4 week cycles for each disease managed. These projects are staggered and run concurrently.

• Week 1 and 2 focus on design and validation.
• Week 3 is build, validation, and testing.
• Week 4 launches our program

It takes an additional month or two of up-front work to identify the high value disease targets. Completed by the project lead; this involves interviewing physician department leads, executives, and other stakeholders to define the order and budget to complete the project.

A project team would include:

1. Project lead / Project Manager– someone to coordinate activities of the team, line up clinical experts, and direct project work. This person is also responsible for overall project success, timelines, and progress.
2. Build team:
   1. Report writer (including registry reports and business intelligence dashboards)
   2. Clinical content builder (the tools to modify behavior within the clinics and in patients)
3. Subject Matter Experts – These are your clinicians who focus on treating the disease

Conclusion

Following these steps, your organization can implement a Population Health Management program. Every organization is different. Your designs will vary based on organizational structure, capabilities, budget, and your population’s specific health needs.

Once your organization has successfully implemented population health and chronic disease management, your organization should move onto continuous improvement projects following these measures or benchmark your progress against other healthcare organizations (in your area, and nationally). Additionally, share your successes with your patients and peers. Part of our mission in healthcare is to help people – and sharing your organization’s path to success with other healthcare providers can help the population of our nation and shape the conversation in the future.

If you have any questions on how your organization can complete these projects, feel free to reach out to me directly through my personal email.