Four Population Health Management Strategies that Help Organizations Improve Outcomes

Population health management (PHM) strategies help organizations achieve sustainable outcomes improvement by guiding transformation across the continuum of care, versus focusing improvement resources on limited populations and acute care. Because population health comprises the complete picture of individual and population health (health behaviors, clinical care social and economic factors, and the physical environment), health systems can use PHM strategies to ensure that improvement initiatives comprehensively impact healthcare delivery.

Organizations can leverage four PHM strategies to achieve sustainable improvement:

1. Data transformation
2. Analytic transformation
3. Payment transformation
4. Care transformation

The Real Opportunity of Precision Medicine and How to Not Miss Out

Precision medicine, defined as a new model of patient-powered research that will give clinicians the ability to select the best treatment for an individual patient, holds the key that will allow health IT to merge advances in genomics research with new methods for managing and analyzing large data sets. This will accelerate research and biomedical discoveries. However, clinical improvements are often designed to reduce variation. So, how do systems balance tailoring medicine to each patient with standardizing care? The answer is precise registries. For example, using registries that can account for the most accurate, specific patients and disease, clinicians can use gene variant knowledge bases to provide personalized care.

A Health Catalyst Overview: Learn How a Data-first Strategy Can Drive Increased Outcomes Improvements

A Coalition of the Willing (HAS17)

With just 5% of patients in the United States accounting for approximately 50% of the total cost of care, health care organizations are struggling to blunt the trend. Many are waiting and watching to see what healthcare reform brings. Others began their efforts a decade ago and continue to boldly innovate with new population health models of care funded by risk-based contracts. While many of the early innovators are struggling to deliver a positive return, others are finding success as they pivot their models, giving more attention to data-driven care management strategies that more predictably suggest the right level of care to the right patients at the right time. And still others are willing to redefine ‘whole person’ care as they look beyond the traditional walls of healthcare.

A Coalition of the Willing explores the successes and struggles among care teams from the Camden Coalition, Partners Healthcare, Health Quality Partners, and others, as they discover new methods to make healthcare sustainable while serving the most complex patients in their communities. In important ways, each of these organizations have discovered positive healthcare outcomes with their most complex patients by addressing solutions to housing, employment, behavioral health and social challenges in addition to their traditional healthcare needs. Critics argue the fixes are short term at best, or the result of skewed reporting, while others fear economic catastrophe still awaits these early innovators after their years of effort to prove these new models successful. Can redefining success per-patient, improving targeted interventions, and actively using care management teams actually have a long-term impact? Join us for a closer look.

Enabling Informed Surgical Choices for Breast Cancer Through Shared Decision Making

One out of every eight women in the U.S. will develop breast cancer in her lifetime, and men have a lifetime risk of one in 1,000. This year, over 3.1 million women are currently being treated or have finished treatment for breast cancer.

The Virginia Piper Cancer Institute had clear evidence-based practice guidelines that directed recommendations for early breast cancer treatment options. Even with these evidence-based recommendations, however, the organization’s mastectomy rates were higher than expected.

Recognizing the organization could do better, the breast cancer program committee endorsed the spread of shared decision making for patients with early-stage breast cancer to all Virginia Piper Cancer Institute locations. The spread of shared decision making allowed patients to receive evidence-based information early in their course of care and make informed decisions that aligned with their values and preferences.

Within nine months of implementing a standard process for shared decision-making visits, the Virginia Piper Cancer Institute clinics that have completely adopted the process have made significant progress in engaging patients with early breast cancer in the shared decision-making process:

• 81 percent of eligible patients (207 people) participated in shared decision-making visits.
• 62 percent of the shared decision-making visits were in person.
• 27 percent relative increase in surgical decision of lumpectomy over mastectomy.

Care Transitions Improvements Reduces 30-Day All-Cause Readmissions Saving Nearly $2 Million

Researchers estimate that in just one year, $25 to $45 billion is spent on avoidable complications and unnecessary hospital readmissions, the result of inadequate care coordination and insufficient management of care transitions.

While increasing its efforts to reduce its hospital readmission rate, the University of Texas Medical Branch (UTMB) discovered that it lacked standard discharge processes to address transitions of care, leading to a higher than desired 30-day readmission rate. To address this problem, UTMB implemented several care coordination programs, and leveraged its analytics platform and analytics applications to improve the accuracy and timeliness of data for informing decision making and monitoring performance.

This combination of approaches proved successful, resulting in:

• 14.5 percent relative reduction in 30-day all-cause readmission rate.
• $1.9 million in cost avoidance, the result of a reduction in 30-day all-cause readmission rate.

Mapping the impact of social determinants of health (Modern Healthcare)