7 Criteria to Identify Population Health Management Targets

Tuesday, June 10th, 2014
This post was written by Patricia Donovan

population health management

Stages one and two of chronic disease are where population health can make the most difference.

The best way to zero in on groups in need of population health management (PHM) is by using robust patient data sets, advises Elizabeth Miller, VP of care management at White Memorial Medical Center, part of Adventist Health. Ms. Miller shares another half-dozen guidelines for identifying likely targets.

How do you find the population you want to zero in on? I recommend you use robust patient data sets, and the way to do that is by risk stratification predictive modeling. I have used DSTHS CareAnalyzer® in two prior organizations and currently use it at Adventist Health/John Hopkins, which is out of Baltimore.

CareAnalyzer looks at predictive modeling, a second tool that predicts the population that’s going to be admitted in the next six months. You can run the data and stratify it and say, ‘These are the individuals that we need to go after first.’ Remember, you’re trying to conserve your dollars, so you’re trying to keep people out of the hospital and as healthy as possible.

CareAnalyzer will also identify those most at risk for disease progression, a third indicator. For example, in congestive heart failure (CHF), the tool will tell you that these patients are stage three, stage four. When you’re looking at PHM, you want to get into patients identified with stage one and stage two. That’s where you’re going to make the most difference. If you’re looking at populations at stage four, they are status quo; their next option is death.

Fourth, you want to look at your high utilizers of care, because they’re using a great deal of care. There’s potential for decreasing procedures, tests, ED visits, hospitalizations. Fifth, there are high-risk individuals; with this group, I recommend that you look for one or more chronic diseases. Do they have hypertension? Diabetes? Chronic obstructive pulmonary disease (COPD)? Look at the chronic diseases.

Sixth, I also suggest that you look at CHF, because if you’re looking at Medicare, this is the highest incidence of readmission, and the highest intensity of cost. COPD is another good one to think about, as are asthma, diabetes, HIV. It depends on your geographic location and your mix of population.

Finally, look at your top 20 percent; they are the highest risk for hospitalization. Remember, you’re looking for quality, but you’re also looking for reduction in healthcare cost. As we all know, hospitalization is our biggest spend.

Excerpted from: Population Health Framework: 27 Strategies to Drive Engagement, Access & Risk Stratification

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