Framing the Issue

Population health management techniques are taking hold in different ways across the country.

Technology is playing a big role in population health management, but so is maintaining the human side of the equation.

Ignoring population health is probably a mistake, argue pop health experts.

From computers that crunch data to human beings who listen, health care organizations are adopting a variety of population health management tools and techniques.

Hospitals, payers and insurers are taking steps to better manage the care of populations with the goal of preventing or limiting medical issues by treating them earlier and more efficiently. Reimbursement for that kind of care has not yet reached the mainstream, but that’s not stopping some hospitals from jumping into pop health management as quickly as they can.

“The hospital systems that are going to be successful are making the investments today,” says David Nash, M.D., dean of the Jefferson School of Population Health at Thomas Jefferson University. “They’re doing the blocking and tackling to be prepared for the game.”

For leaders of Trinity Health, the movement into population health management is driven largely by a desire to take advantage of the organization’s size and breadth to improve Americans’ health while reducing both its own and the nation’s cost of care. With 86 hospitals and 115 continuing care facilities, and home health and hospice programs operating in 21 states, Trinity is trying to measurably alter the health care landscape with its population health strategies.

“We have the ability to truly impact a population of 20 million people,” says Barbara Walters, D.O., executive vice president and chief population health officer for Trinity. “With that breadth, from a population perspective, it’s like being a kid in a candy store.”

Care coordination is central to any population health approach. Back in 2006, Methodist Le Bonheur Healthcare in Memphis, Tenn., partnered with clergy in the most underserved ZIP code regions in the city to create the Congregational Health Network. The goal: to improve access and overall health status of the region’s residents.

The network got a boost in 2014 when Cigna funded a patient navigator position to target the 100 most challenging patients in the region, helping to overcome whatever barriers keep them from accessing care appropriately and following treatment regimens. “That community navigator is one of the core pieces of the program,” say Edward Rafalski, senior vice president of strategic planning and marketing for Methodist Le Bonheur. The individual is placed within the community — “where they’re trusted to help people navigate their health issues.” Things have gone well enough with its first navigator that Cigna and the system decided to add another to target a different health care hot spot.

Similarly, the Illinois Medicaid program has farmed out a portion of its coverage to NextLevel Health, a company that relies on a team of care coordinators to evaluate every assigned member covered by the program. NextLevel Health is located close to the Chicago neighborhoods it serves, which its managers view as key to its effectiveness. The company also uses technology to identify beneficiaries most at risk for health issues and to help determine and manage their care.

TRINITY HEALTH: Fast-paced, people-centered

Trinity Health in Livonia, Mich., adopted a new approach to care under a program called People-Centered 2020 that includes a strong emphasis on managing health from a population perspective.

“We’re taking a very fast-paced, whirlwind approach to it and really trying to push the envelope on it whenever we see the opportunity to do so,” says Paul Harkaway, M.D., senior vice president of clinical integration and accountable care. “We desire to get out in front on the newer model without abandoning our traditional work.”

A few years back, Trinity set up separate legal entities – accountable care organizations or clinically integrated networks — to enact the system’s population health strategies. The ACOs are then responsible for managing the health of defined populations.

The situation under which each entity operates varies; therefore, the degree, pace and way they’ve adopted population health management also varies. “Some places, it’s easier to move fast,” Harkaway says.

Each contract is adapted to fit the marketplace. Some of the models Trinity is using range from a beginner stage in which only its own employees are in risk-based care to more advanced approaches through the Medicare Shared Savings Program for ACOs, risk-based Medicare Advantage programs and commercial risk programs.

“We’re trying to go everywhere fast,” he says.

Trinity Health’s regional health system in Grand Rapids, Mich., Mercy Health, runs a care transitions program to improve outcomes for frail, elderly adults. The transitions program takes a complementary, nondisruptive approach to care.“We are very diligent about understanding what other health care touch points the patients are having,” says Nancy Crowe, R.N., program manager in the division of geriatric medicine at Mercy Health Physician Partners. (A second program is focused on preventive care and management of chronic disease.)

One important aspect of the program, says Carlos Weiss, M.D., an internist, geriatrician and medical director of Mercy Health’s Advanced Care Coordination Program, “is that we try to support existing primary care relationships instead of trying to set up a different program.” Patients can opt to have their care co-managed by their primary care doctors and the transitions program, or they can return to their primary care doctors if they would like to consolidate primary care management in the program.

In one scenario, the hospital might refer a patient to the program, and a quick assessment determines if the individual meets some basic criteria. Minimum qualifications include having a primary care doctor who is part of the Mercy system, living in the county and having a stable — or at least safe — home situation, Crowe says.

A team member visits with the patient while he or she is still in the hospital to see if the person is interested in participating; if so, the team member contacts the primary care doctor for approval to get involved. The day after a patient is discharged, a physician or nurse practitioner visits the home for one to two hours to get to know the patient and his or her particular needs.

About 250 patients have been referred to the program and close to 190 have entered it, which is considered a good acceptance rate, Crowe says.

Once patients are evaluated, Mercy caregivers tailor visits and care to their needs. An unstable patient in the program might be visited several times a week with frequent phone calls from home care nurses. A participant who is more stable might not get another visit for 30 days or until a needed clinical appointment.

Finding staff to work in the program takes extra care, given the geriatric skills needed and the nature of the job. “A spirit of adventure is often required,” Weiss says.


Methodist Le Bonheur Healthcare wanted to make a big impact on its service area in Memphis, Tenn., by adopting population health management techniques. To do that, it chose an approach known as the Camden Model to identify hot spots in the community with unusually high percentages of frequent health care users. A coalition of churches called the Congregational Health Network already was playing a key role in Methodist Le Bonheur’s community engagement efforts.

Using the Camden Model’s combination of computer analysis and community-based evaluations, Methodist Le Bonheur decided to focus on the 38109 ZIP code area. The predominantly African-American region lies in the southern part of the city, west of Elvis Presley’s Graceland Mansion. The average household income is just under $39,000, compared with the national average of nearly $70,000. Patients there had the highest emergency department utilization and the highest consumption of charity care. The 10 most frequent emergency department visitors in 38109 visited more than 200 times, with most of them also suffering from either depression or mental illness. Within that ZIP code, inpatient volume represented 9 percent of visits and 65 percent of costs, as of 2010. (Continued)