Population Health: The Next Steps You Should Take


Planning, decisive action crucial to population health management

Successful population health management is an exciting, growing strategy for better serving patients and lowering costs. In my experience as a leader of a healthcare organization serving high-need populations, I’ve learned that improving population health requires a two-pronged action plan. First, the culture of the practice needs to be aligned so that every member of the team, from call center staff to front desk staff to clinicians, is enabled and motivated to provide the best possible experience for the patient. Second, robust technological tools and analytic capabilities are essential for adapting to today’s cost-conscious environment by monitoring and encouraging progress toward key goals.

Creating Culture Change in a Pots-ACA Era

Infusing an organization’s culture with a population health mindset starts during the strategic planning process. An important part of this approach is regularly meeting with stakeholders to evaluate the organization’s mission, vision and values. My organization, Blackstone Valley Community Health Care Inc. (BVCHC) is a Federally Qualifi ed Health Center. As such, its board is comprised of 51% patients. This ensures that the patient voice is heard.

Once a strategic plan is in place, it is the responsibility of organizational leaders to set clear expectations and to communicate them regularly. The three expectations that I frequently share with staff and new hires are: 1) we are all here to provide the best patient care possible, 2) we all perform our jobs to the best of our abilities, and 3) we treat every patient and employee with respect, regardless of job title.

We host monthly and quarterly staff meetings in which feedback is solicited from all employees regarding changes to policy. I’ve found this process to be critically important. Top-down management is ineffective on its own; alignment at all levels is required for true change.

For this reason, I’ve also begun conducting our Performance Improvement Committee meetings with all staff present several times a year. While some members of our organization initially felt quality improvement had nothing to do with their roles, my message to them was this: We are all involved, and we all have a part to play in improving patient care and reducing healthcare costs.

hese cultural shifts extend to patient interactions, and Accountable Care Organizations (ACOs) would do well to fully embrace the team-based care coordination concept. Achieving the lofty goal of meeting the Institute for Healthcare Improvement’s Triple Aim — improve the quality of healthcare, improve population health and decrease costs — starts with empowering and engaging each patient in their own care.

A comprehensive care management program has proven to be benefi cial in educating patients about their chronic conditions. Patients who are high utilizers of the healthcare system (i.e., frequent emergency department [ED] visits) also benefit from intervention by care management staff.

At BVCHC, we have fi ve full-time nurse care managers, including one who specializes in behavioral health. The care managers are integrated with the medical teams and provide additional services between appointments so that patients can more fully engage in their own care. They work with the chronically ill and with those identifi ed as being at high risk of utilizing hospital services. Our care managers develop strong relationships with the patients and are quite often the first called when there is a crisis. They help patients with understanding how to manage chronic illnesses such as diabetes, and they also provide assistance with housing and other social services.

The team-based care concept we practice is becoming more institutionalized through the proliferation of Patient-Centered Medical Homes (PCMH) as part of the Affordable Care Act (ACA). Community health centers such as BVCHC have been leaders in the PCMH movement. The theory is simple: The easier it is for patients to access services, the more likely it is that they will use them. At BVCHC, along with family medicine, internal medicine, pediatrics and women’s care, we have integrated dental services, optometry, laboratory services, and outreach and enrollment services. An on-site pharmacy is coming soon. We have had integrated behavioral health since 1996. Behavioral health and the medical teams have been documenting in the same electronic health record system since 2007, allowing for seamless sharing of data and medication management.

We saw the teamwork between staff, patients and our full PCMH system play out in the case of a high-risk patient who was a homeless veteran. One of our nurse care managers reached out to him and discovered that he was living in a garage after losing all of his belongings. He was sleeping on a lawn chair, using an electric heater. He was using the ED often because the cold winter months in the garage caused frequent pulmonary problems. The care management staff worked with him not just to attend to his physical health, but to provide a continuum of care that included behavioral health, transportation and housing. After six months, with the involvement of the local veterans association, our Community Health team, and Rhode Island’s U.S. Sen. Jack Reed, this gentleman was offered an apartment of his own.

Use Technology to Your Advantage

Healthcare leaders of today need to not only improve care, but also control costs. One of the best ways to do this is through emerging technology. The backbone of an ACO’s potential savings in any contract is an improvement in quality, and quality improvement is nearly impossible to achieve if an organization isn’t able to monitor progress and effect change when necessary.

The ACA encourages healthcare providers to adopt and use electronic health records, which most have done. We’ve found that going a step beyond these requirements by aggregating data from different sources — and then performing analytics — provides important information to care teams. We use this data to help identify gaps in care that can be addressed at the time of the patient visit or between appointments. This includes following up on referrals, lab work and radiology.

Integrating claims data allows providers and clinical staff the opportunity to identify which patients have used the ED often, or are otherwise high utilizers. This can lead to a discussion with the patient around appropriate use of the ED, or when to call the clinic. Data from other sources, such as mobile applications and real-time locator systems, can be integrated as well.

In charting out the planning, management and technological challenges facing an organization adapting to a future based on population health, healthcare leaders may discover they need a tuneup of their skill set. They shouldn’t be afraid to ask for help. I recently completed an Executive Masters in Healthcare Leadership degree, which helped me to implement changes at BVCHC, not just through learning coursework, but through tapping into a vibrant group of physicians, nurses, administrators, device manufacturers, pharmacists and other
experienced professionals from around the world, all dedicated to improving the healthcare system through their unique vantage points. Exploring best practices — whether through continued education or networking — helps executives become empowered to transform their organization to the benefit of staff, patients and community.


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About Author

Christine Hansen

Hansen is the chief operating officer at Blackstone Valley Community Health Care Inc. in Pawtucket, R.I.

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