Population Health and Population Health Management
What is it?
In an interesting article from the CDC about measuring population health outcomes, Dr. R. Gibson Parrish begins the definition of population health with the WHO definition of health. Essentially, the WHO says that being healthy is more than just not being sick; it’s being in a state of “complete well-being”.
Broadening this definition to include population can take many forms. Which population are we talking about? Population health usually assumes stratifying a larger population into smaller, specific categories, to more accurately measure the health outcomes and to better assess the interventions. This definition focuses on health outcomes of the individual and their distribution across a group, where the “group” delineations align with socio-economic demographics such as those from the Census Bureau. While these approaches look at non-health characteristics of a population and then look at health issues they face, a population may instead be formed by looking at people with the same condition, diabetes, for example, and then at the additional health issues they may face.
In addition to defining population health, the paper “Population Health in the Affordable Care Act Era”, also distinguishes the term population management, shifting from a conversation about a static state of being to an active progression toward improvement.
So, we might start our definition by saying that population health management is the process of improving outcomes of a group by bringing the condition of the individuals in that group to a state of complete well-being.
When we talk about population health management, we think about it across a spectrum that includes information, intervention, and accountability. We approach the following challenges in a population health engagement:
- Identifying a population [cohort]
- Quantifying risks facing that population
- Utilizing data to gain insight to the needs of the population, to design interventions, and to assess the success of interventions
- Reducing costs through more targeted care and improved outcomes
- Facilitating communication between patients, providers, and payers
A path to success
Successful population health management starts with clear goals. For us, it often starts with analytical insight to pinpoint where to focus management efforts.
- What are the biggest health concerns for the patients you care for?
- What are the threads connecting your sickest patients, and how can you make improvements in their health?
- Where should you focus your time and energy to achieve the greatest impact?
- How will you know you’ve achieved that impact?
#2: Leadership engagement
Once you’ve internalized a definition for population and health and management for your organization and your initiative, we go back to one of our favorite concepts around here: leadership engagement. We recognize the challenges involved in effectively communicating from the leadership level, and we also recognize the irreplaceable value it adds to the success of an endeavor.
- Do your clinicians understand the data behind your focus?
- For example, are you seeing increased visits to urgent care and the ED for kids with asthma, prompting an asthma management initiative?
- Are your executives vocally supportive of the changes in policies, procedures, and staff workflows?
- For example, are they paving the way for increasing your discharge communication process to include daily follow-up phone calls to support your efforts to reduce readmission rates?
In terms of population health management projects, we look at accountability in two ways – both as part of following through on your plan and as part of evaluating the plan’s efficacy.
We love to come back full-circle to assess our projects, using meaningful data and relevant information to illustrate impact. In addition to digging in to the questions below, we’re always looking for the why, or the root cause for the success or the challenge:
- Did your initiative align with your population’s needs?
- Were your interventions effective?
- Did your patient population’s outcomes improve? If so, did they improve as much as you’d predicted in your planning stage? If not, what needs to improve?
Why we’re excited
We’re excited that population health and the management of improving outcomes for a group are buzzwords these days, because it’s exactly where we see our healthcare approach in this technology-centric space: data-driven, outcomes-oriented, and designed with the needs of patients at the center.
Our final Buzzwords 101 post will be on another topic that we love to talk about – Data Governance, or, the art of purposeful infrastructure.