Healthcare News & Insights

Population health management: Focusing your facility’s efforts

Through population health management, providers can improve both clinical and financial outcomes. But that’s easier said than done. In this guest post, Sandeep Misra, global strategy leader of population health management at a company that delivers technology-enabled services and solutions, will help your organization focus your population health management efforts.


While population health management is recognized as a critical skill for success in a value-based reimbursement environment, adoption has been uneven. This is due, in part, to the complexity of the task. It’s not one domain, but many acting together.

At the front end, you have to have analytics to identify and quantify risk, as well as to identify gaps in care. That, in itself, is a complex process, requiring sophisticated data integration capabilities in addition to the analytics needed. But once you have a thorough profile of the risks in your population and a good idea of where the gaps in care lie, you are only at the beginning. The next part is far more complex: addressing the risks and gaps in care. This requires an ability to address each individual’s unique needs, which can span a wide spectrum of clinical needs, social services, transportation, communication, education and coaching.

Most healthcare provider organizations deploy third-party technologies in conjunction with their own internal resources (nurses, care managers and health coaches/educators) to perform care management. Others, such as health plans, outsource this function. Either of those can work, as long as providers are constantly informed and actively involved in care decisions. To be successful in the long term and with the greatest number of patients, care coordination systems must do two things: connect patients more closely with care providers and provide support services specific to their medical, social and practical needs.

Build program in stages

Like most complex tasks, building a population health management program should be done in stages. Some of the tasks will be done in tandem, while others will be done in sequence. Some organizations will focus on developing their care coordination systems, because a significant amount of population risk is self-evident, and it gives them a way to address the known needs. Effective analytics to identify the cohorts of patients who can be immediately helped by effective care coordination techniques serves as a very efficient method of achieving quick and meaningful results.

There are many factors that contribute to the patients overall risk and cost impact to the health system. Identifying these patients by incorporating clinical, social and claims data can be very helpful in augmenting or designing new/improved care management protocols that are specific to cohorts of patients with similar needs.

Different approaches

Some organizations have taken a holistic view and provide support across a wide array of patients, while others have focused on traditionally quantifiable metrics, such as excessive use of ER, frequent hospitalizations, or high rates of readmission, all of which can be an indication that a patient is disconnected from primary care systems or has socio-economic barriers to care. Tackling these known problems alone can greatly improve care and reduce use of expensive resources, but may leave many other needs unaddressed.

The result of all this complexity and variation is that no one really knows how well the U.S. is doing as a nation in developing the systems and protocols needed to reach the triple aim – better outcomes, lower costs and a better patient experience.

Instead organizations should look to implement an assessment tool that serves two purposes: first, help organizations consider and assess the maturity of their own efforts; second, provide high-level insights into how provider organizations are progressing toward effective population health management for success in value-based care. By using this tool, organizations can have more data to benchmark their efforts, allowing decision makers to better understand areas where the organization needs assistance. And with more information, a clear vision and strategy will emerge.

Sandeep Misra is the global strategy leader, population health management at NTT DATA Services, a company that delivers technology-enabled services and solutions through consulting, managing service, projects, outsourcing and cloud-based solutions.



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