Issue link: https://beckershealthcare.uberflip.com/i/731691
33 Executive Briefing Along with high-risk populations, organiza- tions should focus on the rising risk group, those patients with identifiable and prevent- able health risks who have not yet become high utilizers of care. Effectively managing these populations requires that leaders con- sider how health is impacted by economic, mental health and other psychosocial factors — an approach more common in public health. "We need to collect social determinants of health data and set the patient in the context of their life. It may not change the interven- tion, but it may change how and where that intervention is implemented," says Elizabeth Majestic, Vice President of Population Health at Cottage Health. 2. Build a Fully Integrated System Leaders agreed that a population health mod- el most likely to succeed under risk is fully in- tegrated; a system with diversified revenue streams and strong regional partnerships and affiliations with community groups, payers, and other providers. Organizations will need to embrace alignment and share patient data among a network of medical and community groups that serve a given population. Leaders also agree that organizations have to shed their fee-for-service culture and em- brace a team-based mentality that has pro- viders working together to meet the needs of a community. "We have to move away from this model that serves self-interest," says Larry Mullins, CEO of Corvallis, Ore.-based Samaritan Health Services. "Whether they are hospital interests, physicians' interests, or ambulatory surgery interests, that doesn't work when you're getting into population health. You're talking about allocating a finite amount of resources for a defined popula- tion and you really can't have one player try- ing to dominate out of self-interest." Leaders agreed that they still have work to do on identifying compensation models that make the most sense and motivate providers to be part of a well-integrated care team. 3. Develop a Population Health Workforce One of the most important leadership priori- ties is to engage and support physicians and staff on the front lines of care delivery as they take on new roles and responsibilities within the organization. The roundtable participants all agreed physi- cians must be allowed to focus on providing high-quality, efficient care for their patients and not be asked to spend more time on administrative work. Organizations can have staff assume such tasks such as data entry, maintaining EMRs or patient outreach and monitoring. Many leaders believe that spe- cially-trained 'population health managers' will emerge as crucial supports to primary care physicians, much like certified medi- cal assistants or the care coordinator in the medical home model. "The population health piece is not a conversation with the provider," says Tom Kloos, MD, president and CEO of Summit, N.J.-based Optimus Healthcare Part- ners, vice president of Atlantic Health System, president of the Atlantic ACO and executive director of MSO Services. "We try to leverage the clinical coordinator that's identified with- in each PCP office. They're the ones who do the outreach. They're the ones who assess the population that the practice serves." Organizations that want to move into the population health space will require both leaders and staff to develop new skill sets. Some are actively promoting the redesign of medical school training; others envision new roles for staff to lead population health efforts and create relevant support systems for physicians and patients. 4. Design Data Systems to Support Popu- lation Health In order to be effective in population health, organizations need effective ongoing data aggregation across their populations. Some healthcare IT vendors are providing data aggregation as a service, using the cloud to bring together a patient's clinical, financial and demographic data to provide a com- plete picture of care. Integrating disparate EMR and claims data enables organizations to better address care gaps and manage care across the patient population. Organizations also need clinical and financial data in real time across the enterprise. Hav- ing "situational awareness" at the moment of care gives organizations the transparency needed to control costs and better coordi- nate care. "Our primary care doctors hear over and over again 'you're the gatekeep- er. You're the one who controls the costs on down the line,'" says Anna Loengard, MD, CMO of Honolulu-based The Queens Clin- ically Integrated Network, Queen's Health Systems. "If they could have a single EMR where they could see a patient- centered view of that patient's care, and also know the cost of care for various referrals down the line, that that would take us a long way." 5. Moving Care Beyond the Doctor's Office Population health leaders should maximize a multi-channel approach to managing patients, including traditional patient visits, but expand- ing use of online, mobile and telemedicine options. Leaders understand that to really succeed under risk or value-based contracts, organizations will ultimately need to better engage patients and impact their behavior in the time outside of the typical 15-minute office-based encounter. "There are lots of people that want more from their primary care doctor," says Bill Winkenwerder, MD, chairman of Winkenwerder Strategies. "They want that interaction, they want to be guided, and they want it now. Most practices are not set up for that. There needs to be a new layer where you can just either call or go onto the web, have an app on your phone, and within 30 to 60 sec- onds, you're talking to a doctor." This kind of immediacy requires exploring such enhanced operational capabilities as open access scheduling, user-friendly pa- tient portals, secure text messaging, care management mobile apps, and live and au- tomated messaging. To really impact popu- lation health, organizations must move their outreach and patient engagement more ag- gressively into the ever-growing digital space. "You want your population to be able to ac- cess the care services they need through the mechanism that works for them," says John Hitt, Chief Medical Quality Officer at Minneap- olis-based Hennepin County Health System. Conclusion Going forward, healthcare delivery systems will need strong leadership to navigate the "murky" transition to population health. Many organizations are so fragmented that the most important job for leaders will be advancing a vision, building consensus and effectively communicating evolving priorities — before they get into tackling the nuts and bolts of delivering care. The future is not about surviving or thriving in a risk contract or simply taking on new methods of reimbursement. That's a small goal. If healthcare leaders want a big, auda- cious goal, they should be rethinking how to manage entire populations and create care delivery mechanisms to support this new ap- proach. The changes will require the devel- opment of new capabilities, and new strate- gies, but they will be beneficial. We can't cross the chasm into population health with a series of small, isolated steps. We are at the cliff's edge and it is time to build the bridge — even if there is significant ambiguity about what rewards await at the other side. 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