What is Population Health Management (PHM)?

Population health management (PHM) refers to a concentrated holistic approach to improving the patient health outcomes of a group of individuals. These individuals are part of a larger group that could consist of people within a predetermined health system, a geographic area, those with a specific disease or ones sharing another defining characteristic. The move away from patient fee-for-service to a value-based model has made managing population health the focus for most  Accountable Care Organizations (ACO), insurance providers, quality improvement agencies, health care systems and health care providers as they strive for the provision of quality care at less cost.

PHM involves applying public health concepts to chronic disease management with a comprehensive data analysis. The goal includes seeking methods to improve patient outcomes and control overall costs. The information gathered can assist in finding and filling patient care gaps and developing actionable treatment steps to care for individual patients, or specific groups. A provider may benefit from implementing PHM strategies as it can aide in the transition to value-based care and reimbursement.

Elements for Population Health Management (PHM)

PHM requires a combination of clinical, financial and operational data that can provide actionable steps and predictable analytics. This information is gathered through the utilization of health IT. Health IT is most beneficial when it can monitor and analyze data about a patient population, provide the ability to draw conclusions from the data, and then develop a clinical picture of a population to help manage the specific diseases within it.

Although data collection and technology are essential for PHM, a few other elements are beneficial in improving the health outcomes of a specific patient population. Those include:

  • Robust care management is cohesive and features well-managed objectives supported by the provider and the patient. These objectives can vary based upon organizational goals, but most focus on improving the patient’s ability to self-manage their care and medication. Patient compliance and self-motivation can contribute to the reduction of the cost of care and readmission.
  • Data collection that can provide real-time insights and information regarding social determinants and claims data. This should include tools to track, analyze and submit data that is required to report for financial incentives and in meeting compliance regulations.
  • Utilizing patient risk scores regarding health, lifestyle and medical history to create subpopulations through the division of a patient population. This method of risk stratification can help the provider understand their health care needs and trends.
  • The creation of a complete, comprehensive patient population profile can assist with identifying patients at risk for readmission and create patient-specific care plans.
  • The motivation to act with information gathered using efficient EHR technology that could assist with notifying patients, making appointments, referring, and securely share data within the network.
  • Striving to empower patients to have a higher level of engagement, education and participation in their care. The provision of tools, resources, clinical support and methods of prevention and care self-management can assist in keeping the patient motivated to make and maintain changes outside of the care setting.

Benefits of Population Health Management

PHM can help in determining how to make evidence-based decisions from data analysis. This can assist in choosing how to best allocate resources across health care settings to improve organized efforts to coordinate clinical care at lower costs. The information gathered from comprehensive PHM data collection can provide an overall picture of the risk, incidence, prevalence and trends of chronic diseases to compare and benchmark across providers.

With a growing aging population and chronic disease burden, PHM can provide the ability to be proactive with health care treatment and prevention. This may aide in empowering patients to play a bigger role in managing their health. Other potential benefits of PHM include:

  • Financial improvement for the organization may occur by determining the utilization of necessary services to assist in the mitigation of costs.
  • Better health outcomes with a focus on the prevention and management of chronic diseases and the identification of care gaps by assessing the health of the patient population. This can enable the provider to identify the greatest health care needs of the patient population for improved disease management and the appropriate allocation of health care resources.
  • Increased patient engagement and the motivation to maintain wellness through preventative care may assist patients with improvement before moving into high-risk groups.

The Road to Success

Although the definitions for population health management may vary, the goal of balancing quality and cost for the delivery of patient care remains the same. The utilization of adequate technology that can collect and analyze the necessary comprehensive patient data can help. This patient data analysis can assist in paving a path to improving population health management that could lead to positive rewards for the patient and provider.



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