Collaboration, Medication Reconciliation, Yoga Key to Successful Population Health Management

Thursday, January 30th, 2014
This post was written by Cheryl Miller


Zumba, yoga, Thank God it’s Free Fruit Friday (TGIFF)?

Maybe not top-of-mind elements of accountable care, but all three are helping healthy employees to stay healthy, and luring others to engage in their own health self-management, the keys to successful population health management (PHM), says Elizabeth Miller, vice president of care management at White Memorial Medical Center, part of Adventist Health, in a recent webinar at the Healthcare Intelligence Network.

In Managing Risk in Population Health Management, Ms. Miller shared the key features of the PHM program at White Memorial, the program’s impact on Adventist’s 27,000 employees and how the program was being rolled out to its patient population.

By incorporating elements of the Triple Aim, and collaborating with all stakeholders, including patients, providers, health plans, employers, hospitals and local community members, a PHM program can achieve optimal outcomes, including minimizing the need for ED visits, lowering costs, maintaining and improving individuals’ health across the continuum of care, and reducing readmissions, Miller says.

Medication reconciliation plays a key part in preventing populations from being admitted or readmitted to the hospital, Miller continues, because it is one of the chief causes for readmission. She cites numerous instances where nurse practitioners go into people’s homes to do medication reconciliation only to find that they are going to two cardiologists simultaneously and taking medications from both of them, not realizing how detrimental it is to their health.

Elements of the PHM program include using robust data sets, risk stratification, and predictive modeling to identify populations, and target high-risk individuals with one or more chronic diseases, including the top five: coronary heart failure (CHF), chronic obstructive pulmonary disease (COPD), asthma, diabetes, HIV. Once eligible populations are targeted and enrollment criteria met, analytics, intervention and program development are established for the top 5 percent, or very high risk, and 10 percent, or high risk, and then wellness programs for the 85 percent, or medium risk.

Ongoing assessments and evaluations of interventions follow, usually by care managers, including periodic reassessments of goals, and measuring outcomes with set metrics.

The goal of any PHM plan is to eventually graduate patients by setting up decision support and self-management tools that will help them do so. Offering employees the right incentives is a key contributor to this. White Memorial was able to engage 95 percent of its employee population in a PHM program by reducing monthly insurance premiums by $50 a month. That percentage grew to 98 percent when the reductions were extended to employees’ spouses,’ Miller says.

Ultimately, says Miller, “we really want to focus on the population and modify the behaviors so that we prevent illness in the future. Right now we have a disproportionate investment in illness after it has already occurred. Once it has occurred, it’s difficult to manage and treat…Our goal is to keep the population as healthy as possible.”

It can be labor intensive, Miller points out, but the outcomes are worth it. Improved health status leads to improved performance, and projected financial savings of $49 million by 2017.

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