Population health management requires a new financial and clinical approachp>

Personalization. We want it in our social media site recommendations. Talent development professionals tailor learning content, personalizing it based on employee preference and knowledge. Healthcare, too, is now being personalized.

Population health management, an increasingly popular practice, enables healthcare practitioners to use data to improve patient outcomes, including prioritizing patients for personalized interventions based on risk. Specifically, PHM includes collecting and analyzing data on segments of the patient population to then manage diseases within that population. PHM requires both analysis and action to improve care and financial outcomes.

Through conversations with patients and by reviewing their vitals and medical history, a primary care provider may, for example, understand a patient's propensity toward diabetes or heart disease. A coordinated effort between healthcare providers and a patient to address and change patient lifestyle may stem off diabetes or heart disease through exercise and a better diet.

The shift to PHM shouldn't just be on the radar for those in the healthcare industry. The practice involves partnerships between healthcare organizations and government, schools, academia, nonprofits, and others. For example, a locality that puts in sidewalks can help encourage residents to have healthier habits such as walking. That can improve physical health as well as mental health by reducing depression. And for all healthcare consumers, the drive to reduce healthcare costs is crucial.

The what and why of PHM

PHM focuses on taking care of humans throughout their life journey, rather than addressing their maladies or disease. That changes the healthcare dynamic and relationship between the provider and the patient population from both the financial and clinical side. It also requires a new mindset on the healthcare providers' part.

On the financial side is value-based care, a core component moving healthcare organizations toward PHM. The traditional fee-for-service model reimburses healthcare providers for services rendered, regardless of outcomes or patient experience; PHM reimburses providers based on positive results, which avoid unnecessary procedures and interventions.

"Population health management is dramatically changing the way hospitals do business," says Ike Bennion, a product marketing manager at Cornerstone OnDemand with extensive experience in the healthcare field. "Aging Boomers are putting a strainon our healthcare system; there aren't enough doctors, so we have to change the way both hospitals and the way the teams within those hospitals operate."

Human challenges

Logistical challenges and human factors are hurdles that healthcare organizations will need to overcome before implementing PHM. After all, it means monumental change. And, as we all know, change is hard. So, healthcare staff need to fully understand that this change is going to happen in their facility or system.

Niyum Gandhi, executive vice president and chief population health officer at Mount Sinai Health System, emphasizes the need for "clear, unwavering guidance that this is the direction we're going, coming from our CEO and board." Too often as a consultant, Gandhi saw healthcare staff believing that population health was something that was going to pass rather than the wave of the future. That leeriness evinces itself both on the clinician and nonclinician side.

The message from the senior levels that a facility is indeed moving forward with PHM doesn't auto­matically mean that people will follow, however. Bennion notes the challenge of getting buy-in. If healthcare organizations—specifically, the talent development professionals and the chief quality officer—don't get everyone on board for a change that is going to be a bit of a headache for practitioners and providers, a healthcare facility isn't going to get very far. To do so, Bennion continues, the talent team must "provide the vision for what this is going to mean for the team."

On the nonclinical side especially, the change in the way an organization manages finances is immense. Selling PHM to clinicians can be even more challenging. The shift to value-based care requires some recognition and admission by care providers that the current system has failed patients. "Healthcare practitioners got into the field to help people," explains Gandhi. "And the system as it is architected inhibits them from doing so." So, the healthcare organization's top leaders, along with the talent development team, need to articulate the message in no uncertain terms that it is the system that must change—it is not the clinicians' fault.

Technology challenges

Healthcare technology company Philips explains in its whitepaper Shaping the Future of Healthcare: How Health Systems Can Move Beyond Sick Care to Proactively Keep Populations Healthy that "Without a solution that can translate hundreds of different data points into a single meaningful measurement, you will miss many of those at risk for diabetes. Further, once identified, managing the population of pre-diabetics in an engaging and effective way is a task more daunting than identifying the population in the first place."

In the move to PHM, records and analytics will now play a huge role in healthcare. As it stands, often patient care involves handwritten notes. How does an organization translate that information to the appropriate format? "If I have notes—and it's only a recorded note on paper—about chest pain, for example, it's not going to make its way up into an analytics model," Bennion explains. Thus, it's first necessary for an organization to have a system in place to adjust and rework how medical personnel capture electronic medical records for some of the most critical conditions, such as pulmonary disorders or cardiovascular disorders. Such a tool or system can make a lot of headway in changing healthcare for the better.

"If I had really good records, which wasn't the norm before managed care, I need to keep even better records of patient interactions. I also need a team of data scientists and analysts to help identify at-risk patients, where the facility is making huge financial expenditures and where there is low quality," says Bennion. A facility can make decisions and take action based on that information.

When it comes to big data, and even before that when health records are involved, privacy and ethical matters are often of concern. With population healthcare, the chief quality officer who is using most of the health data should generally be sharing data down to the doctor level, because it makes the doctor more accountable for outcomes, states Bennion. The chief quality officer looks at both the costs and the outcomes and works with the chief nursing officer, chief medical officer, and others to use that data to improve clinical outcomes and reduce costs.

Many technology vendors provide platforms for use in population health, Allscripts, athenahealth, Cerner, HealthCatalyst, and Philips among them. But a healthcare system doesn't absolutely need to go the vendor route—some use homegrown tools. Gandhi explains that, while the tools and systems are getting better, this is still an immature space. Electronic medical records were originally designed to be billing systems, so it's little surprise that they aren't as effective as they could be in providing information critical to population health. Gandhi notes, however, that many electronic medical record vendors are creating tools to use on top of their current systems that are better designed for PHM. By and large, many in the healthcare field are happier with the provider tools available today than those available three years ago.

What's important, Gandhi continues, is ensuring that whatever technology system or tool an organization implements integrates into the hospital and healthcare team's workflow and other pieces of population health.

Getting started with PHM

In addition to ensuring buy-in from healthcare staff, PHM requires breaking down silos that currently exist among the healthcare team. To make inroads, Mount Sinai focuses on the value of the team, with the patient at the center of that team. "The reason the care team is there is to help the patient through their health and wellness life journey," Gandhi says. It begins with the desired outcome and then defines all the things that have to happen to generate that outcome.

"It's easier to talk about the roles that everyone plays in the team with everyone working together to drive that outcome," Gandhi adds. Although it's not a cure-all, Mount Sinai stresses the importance of the team huddle, not only in relation to PHM but more generally. The healthcare team gathers for 10-15 minutes to discuss the patients who are coming in, those who aren't coming in but ought to be, patients they're worried about, and the patients whom the data say team members ought to be worried about; as well as what everyone is going to be doing that day. "It creates a convening mechanism by which everyone on the team interacts," Gandhi explains.

Breaking down silos also requires skills such as communication, problem solving, and planning. Even elements of project management become critical for all members of the care team, explains Bennion.

Because PHM is such a drastic change, it's fundamental that employees understand what it is. The talent development team at Mount Sinai, with the input of others, began with a broad communication of what population health means to the organization. Getting such a baseline understanding, Gandhi says, was absolutely critical. To help its effort, the talent development team created a 12-minute video explaining what PHM is. The team shows the video to every new hire during orientation, from the custodian to the floor nurse to the billing team member. The video emphasizes that the current system is broken and that it's not the caregivers' fault.

Because PHM is fast changing and still in its infancy, training needs are many and must be kept current. Mount Sinai examined its training, redesigned professional development for specific roles, reviewed job descriptions—many of which were tweaked—and revisited its hiring criteria.

The care team's ability to have effective conversations with patients and their families is essential in today's healthcare system. Gandhi explains that doctors and nurses often are trained in the technical expertise and the science of healthcare, while the emphasis on empathy—the most important trait—is lost. PHM requires patients to be intricately involved with their own healthcare, so the conversations between care providers and patients will be tantamount.

What it comes down to for the healthcare provider is "thinking about the patient beyond the encounter, beyond what can be controlled, to decisions that the patient makes every day," Gandhi says.

Role by role

How PHM works out in a hospital on a daily basis is a work in progress. "People are still trying to figure out the right workflows," Bennion explains. "What are the right ways to communicate, from the chief quality officer down to the bottom-line person who is doing screens and initial diagnosis, for example."

To be successful, healthcare organizations—including the talent development team—must help individuals understand their new roles. Doctors, especially the primary care physician, become a bit like a quarterback. They need to leverage not only their knowledge but also use the information they obtain from other care team members, who are behaving in new ways. Some of these other providers had roles that were more transactional—the licensed practical nurse, for example, checked vitals. Now, everyone is on the lookout for signals that could affect patient health. The doctor uses this information to coordinate care across the team.

Under the new model, the healthcare industry as a whole is hiring and using more nursing assistants. The move to PHM changes the pyramid of necessary talent within a facility, Bennion states. There are more individuals early in their career, and those people will turn over more frequently. Therefore, a hospital's talent development team needs a more robust training program to bring them up to scale. Talent development professionals also need to train these new staff initially on the individual aspects of a new clinical setting, even if they've practiced somewhere else before. That is true especially if they have come from a fee-for-service environment.

At Mount Sinai, care management team members receive training on motivational interviewing—an approach for healthcare professionals to help address ambivalence and intrinsic motivation through clinical conversations—to ensure they're effective care managers. "There's role-specific development that we delve deeply into on top of the more foundational aspects," Gandhi sums up.

The wave of the future

At the national level in the United States, there is broadening consensus that where an individual lives has an immense effect on his health. Additionally, a person's education level, economic status, social support, and neighborhood amenities—that is, social determinants of health—all play a role. Healthy People 2030, an initiative of the Centers for Disease Control and Prevention's Office of Disease Prevention and Health Promotion, promotes population health, care coordination, and access to quality healthcare and services for all.

So, while PHM is in its early implementation stages, the possibilities down the road—while they may be rocky with many curves—are promising.