Overview of Population Health: Community Health v. Population Health Management September 5, 2019 Roadmap to Population Health “ I’m on the bus for population health; in fact, I’m driving the bus. But I need help shifting my core business – all of which focuses on sick care – to focus on health and well-being.” --Hospital CEO Stout et al, 2017: Pathways to Population Health: An Invitation to Health Care Change Agents Agenda 1. Population health’s foundational concepts 2. Two key population paradigms 3. Activity & Discussion: Matching populations and pop health activities to Stoto et al. (2017) four portfolios of population health framework (handout will be provided in class) 4. Equity Population Health’s Foundational Concepts Stout et al, 2017: Pathways to Population Health: An Invitation to Health Care Change Agents THINK ∙ PAIR ∙ SHARE • What two domains were portrayed in Stout et al.’s, 2017 “Four Portfolios of Population Health Framework?” • What two concepts of population were described by Gourevitch et al., 2012 (Challenge of Attribution)? Defining populations Defining health Foundational concepts and goals What is Population Health? Population Health Management Community Health (AKA TPM) The delivery of health care services toward the achievement of specific health care-related metrics and outcomes for a defined population…tied to value-based contracts” The health outcomes of a group of individuals, including the distribution of such outcomes within the group” Loehrer, Lewis, Bogan, 2016, Kindig & Stoddart, 2003, AJPH Healthcare Executive What is Population Health? Population Health Management The delivery of health care services toward the achievement of specific health care-related metrics and outcomes for a defined population…tied to value-based contracts” Loehrer, Lewis, Bogan, 2016, Healthcare Executive Stoto, 2014 Conceptualization ACOs and Population Health Management Communitywide Approaches and CHNAs 4 Portfolios Framework, Stout et al, 2017 2 Paradigms, Gourevitch et al., 2012 Attributed/ Empaneled patients Place-based populations Community Health (AKA TPM) The health outcomes of a group of individuals, including the distribution of such outcomes within the group” Kindig & Stoddart, 2003, AJPH ACTIVITY 4 Portfolios of Population Health What populations and activities fit in each portfolio? Stout et al, 2017: Pathways to Population Health: An Invitation to Health Care Change Agents Activity: Match these terms/activities to the appropriate portfolio on prior slide From Day 1: Defining Populations – Two Key Denominators Empaneled Patients Communities Individuals attributed to a provider or health system based on delivery system utilization All persons in a given area at a given time Accountable Health Total Population Health IOM (n.d.) Working Definition of Population Health; Stoto 2013 Defined geographically or by a shared set of characteristics Example: Community v. Population Health Management at MLK Jr. Community Hospital From 3/13/2019 telelecture, Lauren Espy, MPH, Community Benefits Coordinator Community Health v. Population Health Management Community Patients Risk-stratified targeted patients Population Health Management “The design, delivery, The state and of coordination, payment of highcomplete quality healthcare physical, services to manage mental, and the Triple Aim for a social using well-the population bestbeing resources andwe have available to us not merely within the health care the absence system” of disease or infirmity” Lewis, N., 2014, IHI (WHO 1994) “The delivery of A resource for health care services everyday life toward the emphasizing achievement of the extent specific healthto carerelated metrics which an and outcomes for individual ora defined group is able population…tied to tovalue-based realize aspirations contracts” and satisfy Loehrer, Lewis, Bogan, 2016, needs” (WHO Healthcare Executive 1984) “Care delivery across patient populations to improve clinical and financial outcomes through disease management, case management, and demand management” Nelson (2012) PHM In Practice: Risk Stratification >Tailored Interventions 5% of patients; usually with complex disease(s), comorbidities HighRisk Patients RisingRisk Patients Low-Risk Patients 15-35% of patients; with two or more chronic diseases 60-80% of patients; with one wellmanaged condition or no ongoing care management needs Intensive, proactive management, trading high-cost acute care for lowcost complex care management whenever clinically effective to do so Best-in-class population health managers strive to avoid unnecessary spending and prevent escalation in risk profile Top performers strive to keep patients healthy, maintain loyalty to system, collect patient data for immediate response when care needed Adapted from The Advisory Board Company, 2014, “Answers Every Pop Health Leader Should Have” PHM Goals • To keep a patient population as healthy as possible, minimizing the need for expensive interventions such as emergency department visits, hospitalizations, imaging tests, and procedures (Felt-List & Higgins, 2011) • Lower costs + redefine healthcare as an activity that encompasses more than “sick care” • While PHM focuses partly on the high-risk patients who generate the majority of health costs, it systematically addresses the preventive and chronic care needs of every patient Which Portfolio? Stout et al, 2017: Pathways to Population Health: An Invitation to Health Care Change Agents Which Portfolio? Stout et al, 2017: Pathways to Population Health: An Invitation to Health Care Change Agents And what is at the center of the Four Portfolio model? And what is at the center of the Four Portfolio model? • Equity: Everyone has a fair and just opportunity to be healthier. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and the lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care. (RWJF) • Health inequity: Differences in health outcomes between groups within a population that are systematic, avoidable, and unjust. (IHI) Equity v. Equality Preview: Value-based Funding Models • Capitation: A fixed monthly pre-payment for a defined set of services for each patient assigned to the practice (e.g., PMPM payment) • Payment bundling: Link payments for the multiple services beneficiaries received during an episode of care • Shared savings: Incentives for providers to reduce health care spending for a defined patient population by offering them a percentage of net savings realized as a result of their efforts (requires shared risk) Revisit: Key Aspects of Population Health Management • Organized systems of care, made up of care teams who coordinate care across the continuum of care • Risk stratification and chronic care management • Cross-sector collaboration and partnerships for wellness and prevention • HIT, meaningful use, and clinical integration • Focus ‘upstream’ on social determinants of health • Holistic, patient-centered primary care delivered by interdisciplinary care teams • Evidence-based practice • Engaged patients • Valid and standardized metrics • Risk-sharing models of care (ACOs, medical homes) • Accountability: No outcome, no income (value-based payment) Inspiration NEXT WEEK Watch important social determinants videos in class and take in-class video quizzes! Please arrive on time! Turn in quizzes to TAs at end of class.