Strategies for Managing High Risk Populations

Population health management (PHM) has made significant inroads due to the emergence of various integrated delivery systems including patient-centered medical homes, hospital-based readmission prevention programs and accountable care organizations. Population health is broadly defined as the health outcomes of specific groups of people, including the distribution of these outcomes within the group. These groups can be large geographic populations or smaller groups of people such as specific ethnic groups, disabled people, inmates in a prison and so on. PHM also involves providing a wide spectrum of healthcare services that are directed at behavioral changes and encouraging healthy lifestyles to obtain optimal outcomes.

PHM is increasingly being used to target high-risk populations which are defined as populations that lack a regular source of care, have multiple chronic conditions or traditionally non-compliant due to socio-economic or social determinant environmental factors. The PHM approach exhibits a significant overlap with existing care management programs, but offers additional tactics to improve both clinical and financial outcomes of the target populations. Evolving PHM strategies and more complex care management interventions are being deployed and integrated to help case managers that are directly engaged in health activities to understand the changing landscape.

The PHM Model

The main aim of PHM is to improve health outcomes of groups of people by improving the quality of care, providing better access to care and increasing preventive care. PHM has the potential to improve the health care system while at the same time making significant cost reductions. The PHM model is based on utilizing teams of care givers such as care managers, attending physicians and a host of other providers and the patients’ family members. One of the hallmarks of the PHM model is its comprehensive nature and flexibility.

PHM has become more significant due to the shifting reimbursement strategies, including performance-based compensation. More hospital resources are being allocated to outpatient care as opposed to being mainly channeled to inpatients care as was previously the case. PHM requires stakeholders to leverage advances in technology including identifying relevant metrics that fit the needs of the target group, providing culturally competent support services and using various forms of communication.

Several PHM strategic tools for managing high-risk populations are:

Population Health Intelligence Platforms

Population health intelligence platforms are used to provide plan administrators and care teams with secure web-based access to comprehensive financial and clinical information. These platforms access clinical data and other patient data from multiple sources. They also give users easy access to predictive analysis, population risk stratification, hospital admission data, disease registries and referral data. The platform seamlessly connects to data warehouses that store third-party information.

Medical Management Systems

Medical management systems combine people and information to create highly personalized and effective services that are used to manage acute care management, chronic care management, wellness management and utilization management. Accurate integrated data is used by PHM systems to identify at-risk patients, track results, analyze care and support wellness management. This helps patients experience fewer hospital and emergency visits.

Risk Stratification

PHM risk stratification tools are used to identify different population needs across all levels of risk and design the appropriate interventions to address the needs of the population across the entire continuum. These tools use demographics, care patterns, medical conditions and resource utilization to stratify patients into five main categories namely episode of care patients; high risk patients; chronically ill patients; healthy patients but with conditions and healthy patients. Medical providers in healthcare management and decision-making use this information.

Population Engagement

Population engagement services help in motivating patients to become partners in their own healthcare. The aim at building supportive and long-lasting relationships and use third-party data to identify patient needs and foster active relationships between Primary Care Physicians (PCPs) or other healthcare providers and patients.

Predictive Analytics

Predictive analytics tools are used to model medical conditions within population to identify high risk patients long before they require expensive care and is a useful tool in budget planning. Predictive analytic tools are in the early stages of development but will play a significant role in managing health outcomes.

McInnis & Associates Consulting, LLC (M&AC) is a healthcare management consulting firm that specializes in delivering exceptional value by designing solutions that deliver consumer value as well as increasing revenue and market share. Additionally, we are healthcare experts in serving the needs of underserved populations. We have worked with a number of clients in designing population health and health care access strategies for their high risk populations.