With the shift from volume- to value-based payment and care delivery models, hospitals and care systems are exploring different paths for organizational transformation to achieve Triple Aim outcomes — better care, better health and lower costs. This involves going beyond the hospital's traditional role — efforts that are focused on caring and personalizing services for individuals admitted to the hospital — and providing services outside the facility's four walls to more proactively engage patients and communities.

Achieving Triple Aim outcomes

Population health management is one upstream intervention that can achieve Triple Aim outcomes in a value-based environment. It involves integrating preventive principles into care delivery to improve the health of a defined population. Key elements of population health management include identifying health determinants and addressing modifiable factors, promoting health and wellness, and implementing disease prevention and management programs.

Two AHA guides, "Managing Population Health: The Role of the Hospital" and "The Role of Small and Rural Hospitals and Care Systems in Effective Population Health Partnerships," outline how population health serves as a strategic platform to improve health outcomes. These guides explain how population health resides at the intersection of three distinct mechanisms:

  • Increasing the prevalence of evidence-based, preventive health services and behaviors
  • Improving care quality and patient safety
  • Advancing care coordination across the health care continuum

Population health in a value-based environment

In a volume-based environment, hospitals and care systems implement small-scale, disease-specific programs. As the health care field moves toward more value-based payment approaches, organizations will need to create major systemic and cultural shifts to implement population health management.

Successful population health management programs align mission with services that support a defined population and leverage internal and external resources to address community needs. Hospitals and care systems that successfully developed a sustainable population health management program have fee-for-value contracts that incentivize programs to achieve population health goals. Many health care organizations already are going beyond traditional partnerships and collaborating with community organizations, payers and other clinical care sites to address health care issues.

The second curve of population health

A new Hospitals in Pursuit of Excellence guide, "The Second Curve of Population Health," highlights six tactical areas that advance population health management in hospitals and care systems:

  • Value-based reimbursement
  • Seamless care across all settings
  • Proactive and systematic patient education
  • Workplace competencies and education on population health
  • Integrated, comprehensive HIT that supports risk stratification of patients with real-time accessibility
  • Mature community partnerships to collaborate on community-based solutions

The guide provides metrics for evaluating population health initiatives and includes several hospital case studies.

Rhoby Tio, M.P.P.A., is a former program manager for the Health Research & Educational Trust. To access "The Second Curve of Population Health" and other resources on population health management, go towww.hpoe.org.

On the Web

Leadership conference focuses on equity

The Institute for Diversity in Health Management's 2014 National Leadership and Education Conference, "Equity: Moving Beyond Diversity," will be June 12–13 in Chicago. Plenaries and interactive sessions will cover cultural competence training, mental health issues, regulatory and legal implications and more. The conference also offers opportunities to participate in leadership development activities and network with senior health care executives. In addition, results will be shared from "Diversity and Disparities: A Benchmark Study of U.S. Hospitals." The institute, an AHA affiliate, is committed to expanding health care leadership opportunities for ethnically, culturally and racially diverse individuals. For more information, visit www.diversityconnection.org.

2014 TRUST Award recipient

Nancy Schlichting, CEO of Henry Ford Health System in Detroit, will receive the 2014 HRET TRUST Award on July 20 in San Diego, during the Health Forum and AHA Leadership Summit. Schlichting has led HFHS through a dramatic financial turnaround and championed award-winning patient safety, customer service and diversity initiatives. The health system received the 2011 Malcolm Baldrige National Quality Award. Schlichting also serves on many national and community boards. The TRUST Award honors individuals who have exhibited visionary leadership in the health care field. For more information, including sponsorship opportunities and a list of past recipients, visit www.hret.org/trust.

HRET Annual Report

The Health Research & Educational Trust has released "Making an Impact 2013," highlighting the organization's work in leading national projects, including the AHA/HRET Hospital Engagement Network and On the CUSP: Stop CAUTI; research and educational projects, including leadership fellowships; and partnerships, including with the AHA on the Hospitals in Pursuit of Excellence strategic platform. A one-page infographic, "At a Glance: Making an Impact," is part of the annual report. Visit www.hret.org.