Education is one of the seven keys to a successful population health management (PHM) program, explains Elizabeth Miller, vice president of care management at White Memorial Medical Center, part of Adventist Health. You need to gauge whether your population is literate; at Adventist, the patients are largely illiterate, so brochures and educational materials with pictures in them help to bridge that gap.
When presenting a population health management (PHM) program, it is necessary to first consider the optimal outcomes. You have to be able to measure these with the metrics that you set, and be able to monitor and evaluate your outcomes.
Second, the program for population management should always include education. You have to gauge who you are educating; for example, here at Adventist Health in East Los Angeles, southern California, we’re an urban inner city hospital. Our population is 80 percent Hispanic; they’re not as savvy with the latest trends in healthcare. Many times they’re illiterate, and sometimes they’re afraid to admit it, so you have to be very careful when you speak with them. A lot of times we use pictures in our brochures and educational materials to assist them.
Third, you should always consider medication reconciliation. It is one of the chief causes for readmission. If you want to prevent your population from being admitted or readmitted, look at medication reconciliation. Often when we send nurse practitioners (NPs) into the home to do medication reconciliation, they find that their patients are going to two cardiologists and taking medications from both of them, not realizing it is not to their benefit.
Fourth, a good PHM program should include chronic disease management. Chronic disease is one of your high dollar costs, so you really need to consider it.
Fifth, you need to look at self-management disease decision support. You eventually want to graduate your patients in a population health program, so you want to look at several factors, including whether you are setting up decision support and self-management tools that will really help them graduate.
Sixth, look at the coordination of care; you’re going to be collaborating with a lot of different people at the table. Look at how you’re going to coordinate that, how are you going to communicate that. Communication is key, because primary care physicians really want to know what’s happening to their patients and if you can get that information to them in a timely manner, it helps them in their office.
And lastly, one of the features that’s very important is the evaluation — not the evaluation on your end particularly, but on the participants’ end. They can track their progress and then as you track it, you can communicate it back to the health team. You have good information to bring back.
Population Health Framework: 27 Strategies to Drive Engagement, Access & Risk Stratification walks through the elements of Adventist’s population health management program that engages individuals to modify behaviors and prevent illness in the future.