Managing population health in the United States has always intrigued me: Why should hospitals be engaged in these efforts? After all, most of a hospital’s revenue has been generated by providing sick care and performing procedures, not so much by preventing illness.
A few thoughts came to mind as I began to examine this tension:
- Managing the health of the population, primarily disease prevention, has generally fallen into the domain of public health entities rather than hospitals.
- As children growing up in India, we were taught that the greater good or family good surpassed personal need or desire (although this may not have been true in the health care sector!). A more individualistic culture such as one finds in the United States, where “me” generally comes before “we,” is quite unlike that in some European nations, where taking care of “all” is often viewed as benefiting the individual in the long run.
- Social status and ethnicity (the latter being a huge factor in California, the most diverse state in the U.S.) can have a major impact on health status, access and outcomes. These factors may require a greater understanding of the determinants of health, which has not been a focus for most hospitals until relatively recently.
- I recall one of our Health Forum conference speakers in the early 1990s, Trevor Hancock, a senior professor and scholar at the University of Victoria in British Columbia, who led “healthy community” vision workshops for hospital leaders. He would often begin his workshop by asking participants at what location — anywhere at all in the world — they could identify an example of a healthy community. Hancock said that people rarely mentioned a health care setting or hospital. This recurring experience was real eye-opener for the participants.
Given the contradictions, I have been interested in seeing how legislative initiatives, including the Health Maintenance Organization Act of 1973 and, of course, the Affordable Care Act of 2010, have brought improving the health of the population to the forefront of our thinking. The objectives of such measures have been put squarely into the lap of hospitals, which have now been charged with managing the health of the populations they serve — and the population at large.
As John Glaser noted in his June 13 column for H&HN Daily, greater percentages of reimbursements, by both public and private payers, are going to move to value-based contracts.These trends, he says, will accelerate the demand for services and technology that enable health systems and other organizations (health plans, Medicaid, community-based organizations, employers) to jointly manage the health and care of populations. A couple of health systems in California deserve note for their efforts to build their capacities to address this new requirement.
The five T's: success factors for Community Hospital and Health Innovations:
At Community Hospital of the Monterey Peninsula, making the cultural and philosophical shift from volume to value began almost five years ago, President and CEO Steven Packer, M.D., told me. With almost 75 percent of its payments coming from public or government sources, the hospital’s leaders realized they had to find ways to bridge some of the costs of uncompensated care.
Given the relatively small population of the county, they decided their only option was to collaborate with other providers, including competitors. The first step was to create a separate entity that would lead the collaborative efforts and provide the needed distance from the parent organization. They named the entity Community Health Innovations.
Packer stated that the key success factors for Community Hospital and Community Health Innovations have been the five T's:
- Talent: finding and hiring the right executives and staff to engage in a new way of thinking, focusing on population health management and building community partnerships.
- Training: Identifying best practices and learning from them. To that end, Packer and his team worked with the experts at Geisinger Health System to provide intensive training for case managers and care managers in various clinical settings.
- Technology: Realizing that interconnectedness is crucial. To manage the complexities of integrated electronic health records and practice management solutions, Community Health Innovations hired people with health informatics and implementation skills.
- Trustees: Educating governing boards that the move from volume to value will not translate into immediate profits. There will be a period of red ink, said Packer. Senior staff also had to feel comfortable that they were given the necessary leeway to implement their PHM initiatives.
- Time: Building PHM capabilities and implementing them. It’s a time-consuming and all-encompassing effort, said Packer, and cannot be done either part time or in a hurry.
Two other leaders gave me additional insight into Community Health Innovations' journey. Elizabeth Lorenzi, its vice president and chief operating officer, remarked how changing the organization’s identity to one focused on managing population health takes time and hard work.
For Laura Zehm, vice president and chief financial officer of Community Hospital, one of the most important lessons learned from the group's endeavors was that you can’t “overeducate or overcommunicate” with partners, community, staff, patients, employers, health plans or any other parties. Conversations must be held on an ongoing basis.
PHM in practice
John Muir Health in Walnut Creek, Calif. — a system that covers the complete continuum of care, from trauma to acute to nursing and home health — provides a unique opportunity for care integration and coordination.
Christy Kaplan, R.N., vice president of care coordination and integration, and Susan Merrill, director of quality and safety for its ambulatory network, described three keys to the success of John Muir's program for population health:
- Understanding the population being served and looking at the continuum of care from the patient's point of view. Surprisingly, many hospitals that launch PHM programs don’t make the effort to understand the challenges or needs of their constituents. For example, do they need after-hours clinic access or transportation? Study the data and be creative, said Kaplan and Merrill, and figure out constituent needs and barriers to care.
- Focusing on the Quadruple Aim — that is, ensuring the quality of caregivers' work life in addition to improving the quality of care, health of the population and cost of care. This focus has been an important lens with which to look at the simplification of processes, dashboards and so forth, for both patients and providers.
- Developing a “life care plan” for patients. For example, a patient coming into the system with symptoms of heart disease may be guided to a cardiac care plan. Using sophisticated analytics, John Muir now uses this interaction to develop a longitudinal plan of education, prevention, treatment and maintenance to target the patient’s particular needs rather than requiring the patient to navigate the services and offerings on his or her own.
In terms of next steps, Kaplan and Merrill talked about a more robust use of technology that they have already begun to address. The 2013 launch of an electronic health record software program has allowed them to connect with community physicians, health plans and clinics. An example of future innovation may include offering tablet computers in physician offices so patients can complete pre-visit forms that would be readily connected to the electronic health record and MyChart.
Managing the health of diverse populations with often complex and disparate needs is no easy task, but hospitals are diving in and giving it their best efforts. In the end, the patient is the beneficiary; eventually, with well-aligned incentives, hospitals will be, too.
Sita Ananth, M.H.A., is a Napa, Calif.–based consultant and writer specializing in wellness, community health and complementary medicine.