How Risk-Bearing Entities Work Together to Succeed at Population Health

Health systems and other risk-bearing entities (e.g., insurers) tend to function separately around patient care, even when these units vertically integrate. For example, a patient must often have phone calls and meetings about insurance coverage in addition to already time-intensive medical appointments—a lack of collaboration that thwarts optimal patient experience,outcomes improvement, and progress towardsvalue-based care(VBC).

Some forward-thinking healthcare organizations have realized hidden opportunities in bridging this separation between healthcare entities to improve quality and decrease costs of caring for at-risk patient populations. The path to better care and lower cost often lies in breaking down the barriers between elements, enabling a systemwide structure to manage a sustainablepopulation health改善与全风险(按人头计算)人群相关的质量和成本的护理模式。

A Successful Population Health Care Model: Integration Puts Patients at the Center of Care Delivery

尽管承诺提供更综合的医疗服务，但一些医疗保健领导者发现，进一步让高风险患者参与保险比听起来更困难，因为医疗服务往往围绕着医疗服务提供过程而不是患者。例如，一个正在接受癌症治疗等紧急护理的人，除了他们的许多医疗预约外，很可能不愿意就账单和保险范围进行对话。

As an alternative to more time burdens on patients, some organizations take a patient-centered approach, bringing the insurance conversation and othercare managementservices to patients within the flow of care. In such population-based models, as seen as betweenCarle Healthand health planHealth Alliance, interdisciplinary care management teams meet individuals at their providers’ offices or virtually during appointment times to blend care delivery and insurance services (e.g., case management and utilization management).

Entities usedataandanalyticsto identify populations for which a population health care delivery model will have the greatest impact. Organizations that successfully integrate a comprehensive care experience can see positive ROI and meaningful reductions in emergency department (ED) admissions and facilityreadmissions.

How Does an Integrated Model Manages Multiple Populations and Support Value-Based Care?

Value-based payment models vary but generally follow similar structures and key performance indicators (KPIs). These KPIs include quality performance, utilization, and medical-loss ratio. As a result, integration into a single population health delivery model aligns overall activity to larger populations and focuses efforts to drive cost and quality, removing silos and creating a best-in-class care delivery model (Figure 1).

根据上述整合图，在提供者实践中实施成功的人口保健模式需要正确的人员配备和模式设计。This structure includes the following:

• Multidisciplinary work groups to design the new care model for staffing and operations.
• Process mapping to develop process workflows for each position in the new model.
• 风险评分和分析，以实现一个新的综合风险评分，产生可操作的见解和权力识别和分层。
• Provider engagement to engage clinical staff with leadership champions and population health education sessions.
• 项目管理部署标准过程来沟通进度和管理绩效。
• Communication and change management to deploy proactive change management strategies to share timely information.

The Care Place of Delivery: Approach and Methodology

To support their population health care model, Carle Health and Health Alliance conceived the care place of delivery (POD) approach. PODs are embedded sites that utilize care managers and teams at a primary care provider’s (PCP) location. Additionally,virtualPODs leverage clinicians similarly, but do so virtually (e.g., phone calls, online interactions, etc.)

The POD approach capitalizes on naturally occurring care patterns (e.g., PCP visits) with specialty providers serving the same patient population. A clustering software algorithm uses claims data to identify optimal POD settings, and analysts use population density and PCP/specialty patterns to allocate embedded and virtual support for selected POD sites.

聚类算法使用数据，包括患者和提供者全年的互动，以确定具有最多共同互动的提供者。例如，卡尔健康和健康联盟确定了五个社区卫生服务的地点，并评估了整个系统的资源，以支持其人口卫生保健模式。组织只需要添加三个角色即可启用护理模式—一个药剂师和两个患者访问协调员。The resulting model integrates the care experience with the patient at its center (Figure 2).

The Population Health Care Model Operating Model

The population health care operating model combines care team PODs and a care model resource center to achieve the following benefits:

Integrated Care Team PODs

The care team PODs enable better care management via embedded and virtual resources. They also promote more collaboration among clinical care teams and generate a comprehensive view of care across the continuum.

Administrative Support

The population health care model allows administrative support to focus on less complex care management needs, arrange support to address social determinants of health, and conduct patient engagement outreach (e.g., post-discharge follow-up calls).

Technical and Digital Enablers

Technical and digital enablers support virtual visits, use standardized toolkits to enable efficient and effective workflows, automate manual tasks to improve resource efficiency, and analyze data to support proactive patient outreach.

In-person and virtual resources work with the population to identify patients at high-risk. After patients follow-up with their PCPs, the health systems assign the patients care managers, who connect the patients with necessary resources. The patient then consults with the appropriate specialists (e.g., cardiologists and endocrinologists), with efforts to combine appointments to limit travel requirements and conduct other visits virtually. Finally, the patient follows up virtually with her PCP and care manager to assess progress.

Measuring Success in a Population Health Care Model

Organizations can initially measure population health care model effectiveness by tracking KPIs, including sustained participation rate, predicted future costs, per member per month, participant and provider experience, and gaps in care (e.g., hypertension control). As the model matures, systems can look at financial ROI benefit-to-cost ratio, utilization reduction, andquality improvement.

In case of Carle Health and Health Alliance, patients described positive experiences, and KPIs indicated positive outcomes. For example, after factoring inCOVID-19impacts on care delivery, ED utilization rates were down 30 to 45 percent between January and December 2020, and readmission rates decreased by almost 30 percent. Per member per month decreased by 19 percent, and the model’s cost-benefit ratio (ROI and cost avoidance) was 3.1:1. Meanwhile, data showed no reduction in quality of care under the population model.

Integrating for Better Care, Lower Costs

正如卡尔健康和健康联盟所证明的那样，跨承担风险实体的整合是改善护理提供和实现基于价值的目标的有效战略。通过联合力量和使用分析来驱动决策和规模计划，这些组织已经把患者放在护理的中心，确保他们的需求在正确的时间和地点得到满足，以最小的负担。

Additional Reading

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

• Deliver Better Population Health by Avoiding Three Mistakes
• Four Population Health Management Strategies that Help Organizations Improve Outcomes
• Population Health Management: A Path to Value
• Understanding Population Health Management: A Diabetes Example
• Value-Based Care: Four Key Competencies for Success

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