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Population Health Strategies for Small Practices


Here are several ways even the smallest practice can effectively manage the health of its patient population.

Payers are beginning to tell physicians that they must look outside the walls of their practices, and shift their focus from caring for individual patients to caring for whole populations of patients as part of value-based care initiatives. This new approach brings many new pressures: to communicate better with patients and caregivers; to dedicate additional staff to manage patients with chronic disease; and to incorporate new technology.

Population health management (PHM) is the new phraseology that defines the efforts of a single practice or a larger group like a clinically integrated network (CIN) to provide patient services like timely health screenings, cost-effective treatments, nutritional counseling, and staff interventions to keep a patient population healthy and reduce the consumption of healthcare services. But that could be a tall order for a small practice with only a few physicians and limited staff. Fortunately, it is possible to build a PHM program starting with small incremental steps. We asked our experts how to get started, and here's what they said.


Karen Handmaker, vice president of population health strategies for technology company Phytel (a subsidiary of IBM Watson Health), says managing population health involves directing an organization's efforts toward quality-care initiatives like the Institute for Healthcare Improvement's Triple Aim, which strives to reduce the cost of healthcare while improving the patient experience and the health of whole populations. "[The Triple Aim] derives from value, and that is what the whole population health management and value-based payment is built upon," she says.

It may be disheartening for small practices as they consider the cost and investment of time and staff that population health often requires. Large health systems can have vast IT departments at their disposal, an army of community outreach professionals, and more money to fund population health programs. But according to Susan Corneliuson, Washington-based senior manager with consulting firm GE Healthcare Camden Group, joining forces with other physicians via an independent physician association (IPA) or a CIN is an easy way to multiply resources and potentially boost access to more robust technology systems.

Physicians join associations like an IPA or CIN primarily to work together with other physicians and groups or hospital systems to improve the care of their patients and reduce costs through strategies such as economies of scale and care utilization. They are also able to benefit from contracting together with larger service entities and/or payers.

"Part of the benefit of a CIN is that you don't have to give up your independence and become employed. But you can remain in a small practice and still receive the capabilities from that CIN to start delving into the population health arena," Corneliuson says. "Sometimes they will offer electronic health record (EHR) systems … they will have resources in terms of social workers, care managers, patient liaisons, and other individuals that can help manage the practice more effectively."


Many practice-management experts will tell you that it is easier to start down the road of value by taking incremental steps; and to begin in places where your practice already has already demonstrated strength in value-based care. For family physician Michael Munger that place is the Patient-Centered Medical Home (PCMH). "Even if an independent or two-physician practice is not sure whether they want to go through all the certification process (to become a PCMH), this is an aspect of patient-centered care delivery that really allows you to manage your population very effectively," he says. "… Going into population health is going to be key moving forward as we get positioned for value-based purchasing and value-based payment."

This sentiment is something that Handmaker embraces as well. "The initiative to become a PCMH has been adopted by a lot of smaller and medium-sized practices," says Handmaker, "It is a great way to understand and build the competencies that are required for population health management."

Munger, who practices family medicine at St. Luke's South Primary Care in Overland Park, Kan., which is recognized as a National Committee for Quality Assurance Level 3 PCMH, says his group practice is using a data registry function within their EHR system to extract data on individual patients to help care managers close care gaps. The practice employs a registered nurse (RN) to serve as care coordinator for five physicians. So, for instance, if she were focusing on patients with diabetes, she would extract patient data within the EHR to identify those patients who needed, say, a foot exam, an eye exam, or blood work to check their A1C. Once identified, the care coordinator would direct other members of the care team, like medical assistants or front-desk staff, to contact these patients and schedule appointments for care.


For most practices, the single-most useful piece of technology for managing the health of their patient populations will be the EHR. However one problem, according to Handmaker, could be extracting the data in a useful format. "Practices have found that to manage a whole population, especially across multiple EHRs, it is critical to be able to consolidate multiple forces of data, to get a single view of every patient, and cohorts of patients, that can then be added up to get a view of your whole population," she says. One way around this conundrum is affiliation with a large hospital system or CIN that would give practices access to more sophisticated data systems. But barring that, there is technology that small practices can implement that would give them the tools they need to start managing the health of their patient populations.

Population health module/data registry. Not all EHRs have population health management capabilities, but in general, it is usually possible to add on a population health module to allow for data analytics, reporting, and risk stratification. Munger says his practice's EHR has a built-in data registry, allowing it to report clinical data to payers, identify patients with gaps in care, and generate patient reports that give providers an overview of their care for populations of patients. "It can be very sobering to look at your entire panel of individuals with diabetes and say, 'Oh wow, you mean I only have ["x"] percentage [of patients] that are getting done what they need to?'" he says.

EHRs with data registries also permit care coordinators to run any number of reports to identify patients who need services - especially those with chronic diseases like diabetes or cardiovascular disease. Again, there is a range of sophistication and functions in different products, with some high-end systems able to run customized reports and automate patient communication through secure email or text message.  

Handmaker notes that many data registries, while useful, collect disease-specific data in separate registries, which compartmentalize patients by their diseases. But what if those same patients are experiencing other problems such as uncontrolled high blood pressure or gaps in care such as a missed mammogram? That's where a patient-centric data registry could really make a difference. In the best of worlds, it would be far better to be able to see all relevant information about a single patient and much easier to address gaps in care such as missed cancer screenings.HR

Patient portal. Two important components of population health are improved provider-patient communication and better access to care. Both of these aims can be facilitated through a robust patient portal. Corneliuson says it is vital to reach patients where they are most comfortable. So younger patients who are more tech savvy would be more likely to welcome the opportunity to connect with their caregivers through patient portals that allow secure communication, appointment scheduling, lab results, and online payment. "You are connecting patients and getting them engaged in their care and focused on their treatment plan," she says. Another benefit of a patient portal, she adds, is offloading work from practice staff so they can concentrate on clinical tasks like care coordination.

Health information exchange. Because of the challenges with interoperability and cost, health information exchanges (HIE) have had limited uptake with physicians in private practice. But having access to patient data from large, state-wide populations has clear benefits for physicians and their patients. "The point of a HIE or data registry is that you are able to compare your patients against the norm or the average for your area. And then you can figure out what you need to do, based on best practices or guidelines, to better care for your patients," says Corneliuson.

Mobile applications. Mobile health apps can range from simple calorie counters and food logs, to sophisticated glucose monitors that transmit data wirelessly. All are designed to help patients become healthier. Yet, technology that would allow remote monitoring and reporting of patient data to physicians outside of the hospital is still in the early stages. Despite premature technology, says Munger, he thinks there is tremendous potential to help patients better manage their health; especially those with chronic disease. "One of the insurance companies here in the market just came to us and talked about a pilot where we would enroll patients with congestive heart failure and they would give the patients a wireless [device] to upload their weight [and blood pressure] …" he says, "In other words, [there are] a whole host of tools that could be made available to the patient either through a direct transmission to us, or an app, for a lot of chronic disease management."


Community outreach and support can be especially vital in smaller rural communities where access to healthcare can be negatively affected by factors such as limited transportation and distance from care providers. In Western Michigan, the Grand Rapids-based, not-for-profit health system Spectrum Health takes full advantage of population health strategies such as deploying community health workers and telemedicine initiatives like on-demand care from staff physicians via secure e-mail or video.

The advantages to patients seem obvious: better access to care, in-home nursing support, and a better understanding of their chronic diseases. But those benefits are also borne out through the numbers.

In a study conducted by two Spectrum Health hospitals (United and Kelsey) over the period of March 2013 to December 2015, 277 patients with chronic diseases like diabetes or congestive heart failure received monthly in-home care visits by community health workers.

During a 12-month period, patients significantly reduced the number of emergency department visits and inpatient admissions, but also improved on measures of blood pressure, BMI, and increased physical activity. Charges for inpatient readmissions for heart failure patients were reduced by 9.5 percent over the study period and 38.9 percent for diabetes patients. The reduced number of hospital readmissions during the same period translated to a savings of $495,131 for the health system.

Erica Spreyis associate editor for Physicians Practice. She may be reached at erica.sprey@ubm.com.

This article was originally published in the May 2016 issue of Physicians Practice.

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