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Steps To Build A Population Health Model

Step 1: Connect

Population health typically leverages data from practice management systems, laboratory, pharmacy, paid claims, and electronic medical records. Currently, integration of healthcare data is a challenge because it is siloed in different systems and in dominantly in paper format and sketchy information capture in the EMRs across care settings. Active Wellness overcomes this difficulty by offering a cloud-based single data repository. Here the patients / members and care teams generate health transaction across the care continuum. Thus a single data repository is used for acquiring, aggregating, and analyzing data from different stakeholders like care teams, hospitals, labs, and pharmacies. The common data store allows the clinical integration of health transaction and allows Care teams and providers can participate in a population health care delivery model. Organizations can use the Active Wellness Ecosystem to build longitudinal patient records that give a single consolidated view of all the healthcare transactions.

Step 2: Analyse

Data collected needs to be converted into information through the use of healthcare analytics. Analytics is the foundation of population health management that allows segmentation and stratification of the population and successful calculation of risk and the risk being assumed. Organizing the data into actionable insights — the identification of opportunities for improving the quality of health through proactive interventions and reducing cost. This is the true value of healthcare analytics. Key analysis for a population health model include:

  • Analytics: Predictive modeling to stratify patients by clinical and financial risk so that the appropriate level of care management is put toward the level of risk of the population.
  • Patient Consumption Tracking: Track patient cost and utilization across episodes and medical conditions to give a full picture of the patient.
  • Gaps In Care: Identification of gaps in Care for the patients not in compliance with evidence-based guidelines. The ability to identify gaps in care as they happen so that care teams can address them to improve patient outcomes
  • Patient Segmentation: Patient registries to track all patients with respect to specific conditions and recommended care guidelines, ensuring coordinated care across the network
  • Provider Profiling: Undertake variation analysis of Provider practice pattern and to identify outliers by episodes or by utilization in different departments. Providing the focus needed to work with and educate physicians on how to deliver evidence-based, cost-effective care
  • Provider Networks: Network management analysis with respect to network leakage and physician referrals and identify high cost providers.

Step 3: Intervene

Analytics of population identifies members of the population who require intervention— This is across the complete spectrum of care from prevention, Wellness, risk management, and chronic care gaps. Generate a comprehensive care plan, or medication therapy monitoring tracking from addressing what keeps a person from filling and taking prescriptions. The Active Wellness Ecosystem allows enables population health by allowing organizations to create care coordination and care management workflows to proactively drive intervention activities such as:

  • Point-of-care management of gaps in care
  • Integrated assessments, and care plans across multiple conditions, and care plans for transitions in care
  • Rules-based workflows to prioritize care management activities and proactive modification of care plans that are driven by changing patient needs
  • Escalation and de-escalation workflows across the patient population, from the complex chronic patient to patients at risk to though with modifiable lifestyle behavior to those who are well patient
  • Building these patient profiles allows personalized care interventions that work for the patient.

Step 4: Engage

Population health solutions engage on three levels: patients, physicians, and other clinicians, and the provider network.

Patients: Patient engagement is a collaborative approach where the patients' partner in their care plan development. Here the person is involved in the process of combining a care teams information, education and professional advice with self-initiated actions to meet his care needs, and take actions to optimize health and healthcare decisions. In the context of a population health model, strong patient engagement is all about building a strong self-motivation that drives the patients to improve their compliance of tasks and care instructions to result in produce better clinical outcomes.

Toolsets To Promote This Include:

Communication & Outreach: Notify patients of a gap in care with a recommended call to action

Extension of care management: Help patients remain engaged and take ownership of their care plan when they are not directly interacting with the care team.

Patient education and behavior change: Offering tools and patient communities for sharing experiences and knowledge libraries and access content that educate the patients about their conditions and encourage healthy behaviors

Maintaining wellness: Promote healthy behaviors in a population to prevent the long-term development and progression of disease burden in individuals.

Record Health Data: A PHR- EHR interface allows the patients and physicians to record health states and events that allow the care team to identify any variations that need proactive interventions.

Clinician And Physician Engagement Is Also Comprised Of Three Parts

Physician buy-in: This is critical for fostering practice transformation. As such, careful rollout of a population management strategy is important and typically most successful with a physician leader as a champion of the initiative.

Physician Measures: Ensuring that there is physician alignment with the validity of key metrics upon which physicians will be measured is key to success. This includes data validity, proper physician attribution of patients, and acuity adjustments. Only then will physicians become more deeply involved in the measurement process and engage in desired behaviors

Workflows: Easy to use physician workflows are the foundation of the Active Wellness ecosystem and makes adoption that is intuitive and easy. The business-driven technology ensures that the right information is available to the right person at the right time to achieve the quality outcomes and increased efficiency as this is necessary for both the provider network and payers strive for.

Clinical Care Teams: This involves the proactive evaluation and monitoring and steering of patients to most appropriate need-based care teams that will manage them effectively and efficiently with appropriate escalation where needed. This maintains continuity of the care teams and lowers-cost for the clinical need, without compromising quality. For example, strong network management would encourage that a patient with the flu is seen in urgent care rather than the emergency room. Additionally, network engagement involves data-driven management of referral and escalation. This helps the networks more intelligently contract for the population.

Step 5: Support

Active Wellness Ecosystem with the Active Clinical and the services wrapped around it makes the population health model gives a plug and play option. Health plans, Employers and hospital networks can extend their care and move to a value-based population health model. These services lay the foundation for care models, the creation of care teams, payment models, and organizational processes. Active Wellness could provide services that could encompass a variety of domains, such as crafting strategy, assist in practice transformation, provide staff augmentation, or even provide an ecosystem to deliver on population health management.

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