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Making population health work for your practice


A population health management program sounds complicated and expensive, but it does not have to be

Value-based care requirements are becoming increasingly important for independent medical practices and require a shift in how they think about their patient populations.

No longer is the focus only about treating the sick people within a waiting room; it is about empowering patients to better manage their health from their homes, both with preventive care and in living well with chronic illness. No matter the size of the population or organization-whether a medical practice or large health system-population health management (PHM) programs can help to improve outcomes by more effectively addressing patient needs and connecting a practice and its patients to its community.

While the healthcare industry has historically been slow to adapt to change, independent practices should take advantage of population health initiatives. Without the lengthy chain of command and the complexities that many health systems may have in place to implement change, independent medical practices can implement PHM programs faster than larger health systems and drive significant improvements for their patient populations. It is no longer about when or should practices act, but rather how do they start.

If independent practices are thinking that a PHM program sounds complicated and expensive, it does not have to be. Using these tips, independent practices can implement PHM programs that are customized for their patients and continue providing care for their community in the unique way that only independent practices can.

Jump in, and make it manageable
There is no need to tackle a practice’s entire population right out of the gate. Instead, break populations into smaller groups, and choose a low-risk population where simple changes are easily implemented. This approach is a good way for practices to dip their toes in the water, without needing to dive in and invest resources and time.

Setting specific quality metrics to monitor for-whether it is reducing the number of patients who use the emergency department for non-urgent issues or helping patients with diabetes manage their insulin levels better-creates a framework that helps practices determine success. Once practices have achieved their goals in one pilot, they can expand these learnings to others-the key here is to start!

Make a business case to physicians
An advantage that independent practices have is that the leaders are the physicians themselves, and when they buy into a PHM pilot, there is not a need to convince additional stakeholders about its value. While health systems may face a lengthy review process that requires sign off from various members of a c-suite, independent practices have the flexibility to be creative and execute on strategies sooner.

Although approvals to pursue a pilot might be more straightforward, identifying the potential return on investment (ROI) and proving out that ROI is even more critical. The physicians making these decisions are directly impacted in the financial risk. As independent practices plan the change, it’s important to take time to define the benefits and the costs. If the benefits improve a clinical outcome, does it bring in more pay for performance and how much would that be? If it improves access, does it reduce avoidable emergency department visits or allow clinicians to see more patients? There is a tendency to focus on the clinical outcomes, but other outcomes can be quantified. 

Leverage community relationships
When compared to a larger health system, many independent practices assume that they do not have enough financial and technological resources to make a PHM program work. In reality, small practices are likely much more in-tune with the resources available in their community and how to connect with them. They often contribute to the local business community alongside their own patients, allowing them to tap into what is happening in the community, and leverage pre-existing relationships to help them start PHM programs without investing a large amount of resources.

These relationships can be utilized to make a significant impact, from directing patients to local food pantries or coordinating transportation. By leveraging these community relationships, independent practices can make an impact with their PHM pilots without spending a great deal because they do not have to build it themselves.

Be willing to fail early and often
Most changes in healthcare come with a learning curve, and PHM pilots are no different. Some initiatives will not work as intended and that is OK. Leaders need to be able to make corrections and re-measure, or make the decision to abandon an initiative. It is important to have a few key metrics that practices are tracking to determine success, and to be able to recognize when it is time to move on. Pilots are often two to three months, not years in length.  Pilots that have been in place for two to three years are not pilots. They are the way it is done and can be difficult to dismantle.  

Population health is not a one-and-done program, but will be an approach of building a series of programs or pilots based on the needs of patients. The priorities will be different for each practice. Independent practices should avoid getting too bogged down in the complexities of transitioning to value-based care and should focus getting started, one small population at a time. 

Cindy Gaines is chief nursing officer for population health management for Philips.

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© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health