Population Health Management Gains Steam in 2014

This time of year, industry publications and even mainstream media are inundated with editorial on health care trends and predictions for the coming months. As we ramp up for 2014, the timing is perfect for case managers and other providers to evaluate how the medical management system is evolving to support patients.  

Without a doubt, we have observed numerous changes over the years regarding how case management programs are defined and operated. The Affordable Care Act, value-based purchasing, advancements in health information systems, among other factors, have accelerated the pace of change.  

Along with evolving trends come new buzzwords – in our field, "population health management" tops the list. Although this phrase has been around for many years, the population health management (PHM) model has made significant inroads as integrated delivery systems, such as accountable care organizations (ACOs), Patient Centered Medical Homes (PCMH), and hospital readmission prevention programs, have emerged.  

As a result, the practice of case management is evolving to accommodate some of these new opportunities. The emerging PHM approach today overlaps significantly with existing care management programs, but also includes additional tactics to improve the clinical and financial outcomes of the targeted populations. As more complex care management interventions and emerging PHM strategies are deployed and integrated, case managers need to understand the changing landscape.  

The PHM Model
PHM is defined by Kindig and Stoddart as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group."1 The PHM model involves coordinated care efforts that go beyond managing specific "cases" or "situations," to improving the health outcomes of populations, by providing them with a spectrum of services directed at behavioral change and healthy lifestyles to obtain optimal outcomes. PHM is focused on improving health outcomes by providing better access to care, improving the quality of care, and increasing preventive care. In doing so, PHM has the potential to improve the entire healthcare system, while reducing costs.    

Like case management, this model is based on utilizing a team of caregivers, including case managers, attending physicians, family members, and others. Populations and individual patients are targeted across a wide range of medical conditions and social and physical environments. The flexibility and comprehensive nature of the PHM approach is one of its hallmarks.  

Key Elements
The approach to PHM is broad and dynamic. Population health tactics can include:  

• Deployment of population identification and stratification processes;
• Use of risk and needs assessments to assess physical, psychological, economic, and environmental needs;
• Proactive preventive and chronic care to all patients, both during and between encounters;
• Management of high-risk patients to prevent acute episodes; 
• Use of evidence-based protocols to diagnose and treat patients in a consistent, cost-effective manner;
• Reliance on  patient engagement strategies promoting  personal responsibility and self-management; 
• Integration and use of dashboards and reports to use as feedback loops for patients, providers and program sponsors; and
• Programs that promote quality care and efficiency to save costs.

Among other market drivers, PHM is now more important than ever due to shifting reimbursement strategies, such as performance-based compensation. For example, hospital revenues are shifting from inpatient care to outpatient, and physician reimbursements are moving from individuals to entire patient populations, and from volume to value. 

Dozens of factors go into the design and implementation of a successful PHM program. Of course, face-to-face meetings and telephonic interactions will remain indispensable, but leveraging emerging communication assets are also central. Easy tools need to be implemented that encourage patient education, engagement, and self-management. 

For example, millions of patients use the Internet to review test results, schedule appointments, get health information, and email their physicians. The rise in social media interactions to support patient health is another communication trend that is rapidly expanding. Similarly, text messaging, email, online video chat, VOIP-based telephone systems, and other communication channels will increase our ability to stay connected with family, caregivers, providers, and others.

Leveraging remote monitoring, smart phones, and wireless communications also can help optimize PHM strategies and outcomes. With the growing reliance on electronic health records, telemedicine platforms, and technology applications to promote affordable, high-quality person-centered health care, a better understanding of the new mobile environment is now a necessity.

PHM programs also rely heavily on "informatics" and data analytics to identify and measure the effectiveness of population-based interventions and help promote an interconnected health care system. Being able to aggregate and summarize patient health histories, along with the creation of detailed care plans, is essential to managing the ongoing care of the targeted individuals within a group. Technology is the lynchpin to make this happen.  

To that end, care management IT systems will continue to assume a central role to support population health initiatives. Care managers must have access to IT systems that can support the PHM model, including implementing risk-assessments that help create customized care treatment plans, promoting automated workflows and documentation, stratifying opportunities to identify and manage targeted populations, and tracking/reporting financial and clinical outcomes – among other capabilities. It also will be nearly impossible to provide the reporting these programs require without the use of IT systems.   

Final Thoughts
We certainly live in exciting times. The importance of case managers will only grow and expand as the U.S. health care system continues to evolve and population health strategies gain prevalence. Case managers should take advantage of the emerging PHM model to support their ongoing programs. Of course, case managers will continue to stand the test of time as new care management models and tactics come and go in the future. Simply put, we are here to stay!