Achieving Stakeholder Engagement: A Population Health Management Imperative

This report is based on a 2019 Healthcare Analytics Summit presentation given by Susan Seidensticker, BSIE, MSHAI, CPHQ, CSSBB, PMP, Director, Waiver Quality Operations, The University of Texas Medical Branch, and Andrew T. Herndon, MHA, CSSGB, Senior Business Manager, Office of the President, The University of Texas Medical Branch, titled, “Serving the Traditionally Underserved with Population Health Improvements.”

To improve care in avalue-basedmarket, health systems must become competent in population health management (PHM). PHM, however, can be complicated with organizational barriers including information silos and limited resources. To succeed, health systems need multidisciplinary and cross-functional stakeholder support that ensures standard PHM work occurs across the organization. Earning this backing relies on real-time, actionable data and analytics to measure the effectiveness of population health improvements.

An analytics-driven PHM program that engages the stakeholders achieves the following:

• 在旅程的一开始就包含尽可能多的涉众。
• 满足组织独特的分析和报告需求。
• 使用户能够度量并管理PHM结果。
• Provides the real-time analytics VBC requires.

Why Population Health Management Is a Must-Have Competency

PHM comprises strategies that guide transformation across the continuum of care to help organizations achieve sustainable outcomes improvement—versus focusing improvement resources on limited populations and acute care. Population health covers the full spectrum of individual and population health (health behaviors, clinical care, social and economic factors, and the physical environment), making PHM strategies key to ensuring improvement initiatives comprehensively impact healthcare delivery across organizations.

美国卫生系统对PHM的需求有多迫切?By the statistics, PHM is a healthcare imperative, as the nation’s rates of serious medical conditions and associated costs are substantial:

• Six in ten adults in the U.S. have achronic disease. Chronic diseases are the leading drivers of the nation’s $3.5 trillion in annual healthcare costs.
• 4 percent of U.S. women and men will be diagnosed withcancer在他们的一生中。
• One in three American adults hashigh blood pressure, which costs $46 billion in health services, medications, and missed workdays.
• 3 million Americans havediabetes—the nation’s seventh leading cause of death.

By guiding transformation across the continuum of care, PHM strategies help health systems manage concerns they know their populations are at risk for (e.g., addressing the above conditions proactively and reducing reliance on acute care). As well, under PHM’s value-based model (e.g., at-risk contracting and pay-for-performance arrangements), organizations receive enhanced financial incentives for delivering preventive services and tracking patients across the care continuum.

The Scope of PHM Challenges Calls for Stakeholder Engagement

To manage these patients and succeed in PHM, organizations must rely on a new set of data-driven, team-based skills. To address the following broad scope of common population health challenges, organizations must have systemwide stakeholder engagement:

• Achieving provider engagement.
• Measuring provider attribution.
• Accurately identifying the numerator and denominator for each measure.
• Making time to improve population health.
• Capturing and managing the breadth of population health data and turn it into actionable insights.
• 实现数据驱动的优先级排序，以选择改进机会(必须是可操作的当前数据)。

DSRIP: Strengthening the Case for Stakeholder Engagement

In certain states (including California, Texas, Massachusetts, New York, and others), theDelivery System Reform Incentive Payment(DSRIP) program offers performance-based incentives for improving care delivery to Medicaid and other uninsured (underserved) individuals. Under DSRIP, states have millions of dollar available for reinvestment annually, most of which are tied to clinical outcomes.

DSRIP goals tied to PHM include reducing the total medical spend, improving patient outcomes, and establishing a direct link between provider performance and payment.

In Texas, for example, DSRIP ties payments to performance in 30 measures tied to 32 rates for traditionally underserved populations. DSRIP gives health systems in Texas the opportunity to earn millions of dollars in incentives, which can drive stakeholder interest in improving care for underserved populations—especially when organizational objectives align, and real-time data measures improvement.

Aligning End-User Requirements with Organizational Objectives

Improvement teams can earn stakeholder engagement in PHM programs, such as DSRIP, by choosing measures that align with strategic objectives (e.g., reducing emergency department visits). In Texas, for example, theUniversity of Texas Medical Branch(UTMB) picked primary care measures for DSRIP and identified opportunities for improvement to earn incentives while also supporting organizational goals.

Achieving PHM, and DSRIP incentives, requires health systems to select strategic improvement opportunities to maximize quality care and revenue:

• Establish a broad portfolio of team-based efforts across multiple care settings.
• Use custom reports developed by internal the clinical data management team to select quality outcome measures (“bundles”) that best align with organizational clinical strategy (e.g., diabetes, heart disease, adult primary care, cancer screening, and pediatric primary care).
• Evaluate which measures may be beyond the organization’s current scope.
• 利用尽可能接近实时的数据(与月度或季度报告相比)来实现目标。

Dynamic Reporting Leverages Real-Time Data and Analytics

From securing stakeholder engagement to achieving PHM goal, organizations must leverage real-time data and analytics. VBC is the new norm, and it requires real-time analytics to measure performance and measures as needed to succeed in PHM.

An advanced analytics tool for PHM must be capable of compound measure stratification and proactive (versus reactive) patient outreach. It must also trend data over time to gauge intervention effectiveness, show historical context (e.g., whether trending up or down), support attribution models, and refresh daily.

Example capabilities of an advanced PHM application include: filtering by disease, location, department, and provider; displaying composite scores and individual measure scores; and graphing individual measure performance over time. This insight helps organizations improve clinical processes by improving pre-visit planning and proactive patient outreach; implementing standardize clinic workflows; and sharing ongoing, timely feedback with clinics and providers.

Data Earns Stakeholder Engagement in the PHM Journey

由于PHM挑战的广度和深度包括从一线临床医生参与到实时可操作数据的连续护理，卫生系统必须有全组织的利益攸关方参与，以影响基于人口的改善。DSRIP各州的组织可能更清楚地说明PHM面临的挑战和机遇，但任何卫生系统都将受益于利益攸关方参与的实时数据和分析方法。

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

1. Introducing the Health Catalyst Population Health Foundations Solution: A Data- and Analytics-first Approach to PHM
2. Pairing HIE Data with an Analytics Platform: Four Key Improvement Categories
3. Social Determinants of Health: Tools to Leverage Today’s Data Imperative
4. Machine Learning and Feature Selection for Population Health

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