How To Manage Population Health Management

If it rains every day this week, does that give you enough information to know what the weather will be in 6 months?

If a patient was in the hospital this week, does that give you enough information to know the status of that person’s health in 6 months?

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Everyone’s focus on Population Health Management (PHM) is on data, data that represents only a snapshot of someone’s health.

The focus should be on all of the patients, all of the time…• You cannot manage the health of patients for whom you have no data.• You cannot manage the health of a patient for whom you only have a

snapshot of data.• How much data do you have about someone who does not come to the

hospital this year?

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A Healthcare IT Vendor will not solve your PHM problem.

HIT Vendors will help you…• Collect data• Store data • Massage data• Evaluate data

But…

What data do you have for people who are not in the hospital?

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The PHM investment is very costly, and the ROI is uncertain.

It is especially costly when the investment must be amortized against only a small percentage of the your patients using only a snapshot of their data.

The smaller the size of the “population” you include, the greater the chance is that you will not be managing anything.

“The Law of Small Numbers”…sometimes referred to as the Law of Hasty Generalization, and the Pigeonhole Principle

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There aren't enough small numbers to meet the many demands made of them. The Law of Small Numbers makes PHN efforts insufficient, ineffective, and inefficient.

Can you forecast and manage someone’s health…• Who is not in the hospital• Who was not in the hospital• Who was never a patient

The population to be managed is considerably bigger than the population the hospital is trying to manage.

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Does care coordination work?

How can care coordination be effective when the people whose care needs coordinating are not in the hospital?

• How do you model predictive risk data from a fraction of the patients in your service radius and whose data exists for only a small fraction of the days of the year

• How do you manage health when patient stakeholders only yield data when they are in the hospital

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Is there a really a care continuum under the current PHM efforts?

Where is the care continuum…• Continuum of care is a concept involving an integrated system of care that

guides and tracks patient over time through a comprehensive array of health services spanning all levels of intensity of care (NIH)

• How can a provider guide people over time if they only see them for a brief period of time?

• How can a provider know what is going on with patients if the patients have no way of communicating their wellness?

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Providers’ PHM tools and initiatives are 1-way and often include:

• Prevention• Advocacy• Promotion• Coordination• Management• Analytics• HIT• Assessments• Screening

What tools do the patients have to communicate their health to the provider?

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Over a given year, what does the hospital really know about the patients who comprise their population and about whose health they are managing?

• Behavioral changes• Adherence to their medication• Overall health• Risk

How can a hospital know any of these things when the patient is not in the hospital and has no way to communicate their status?

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For a provider to manage the health of the population it needs to know the health of its patients across an uninterrupted period.Hospitals should:

• Create a 2-way communication vehicle (ACCESS) that allows patients who want to manage their health to input information about their health on a regular basis

• Establish automated alarms that report when a patient’s information suggests there could be a health problem

• Know when to contact the patient based on input from the patient

This same process can also reduce readmissions.

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