3 lessons from population health innovators

Hospital CEO: 'We won't know what's possible in pushing the envelope if we don't try new things'

By Sam Bernstein, Senior Staff Writer

The transition to population health is driving a massive wave of innovation in the health care industry—and organizations leading the charge are thinking about  return on investment (ROI) in new ways, Advisory Board's Tomi Ogundimu told the Daily Briefing.

"When I look at the innovative institutions, they rarely communicate ROI using a single metric," said Ogundimu, a practice manager of Population Health Advisor. "They tie ROI to the goal of the new intervention, whether that is to reduce readmissions, increase patient engagement, decrease hospital bed days, or all of the above."

So how are leading organizations innovating on driving care transformation? Ogundimu told the Daily Briefing about three lessons drawn from their experience.

Join our March 30 conversation on evolving population health management practices and care models

1. Primary care doesn't have to be one-size-fits-all.

One way health systems are innovating on population health is by acknowledging that not all patients have the same priorities and same needs—and then developing strategies to appeal to particular patient populations.

For instance, Stanford Medicine launched its ClickWell virtual care platform with the goal of shifting care for its lowest acuity patients to a low-overhead virtual platform. Stanford saved 30 to 40 percent per appointment on costs and provided more convenient access to care for a low-utilization ACO population.

Meanwhile, Denver Health launched an intensive outpatient clinic to appeal to ED super-utilizers who had two or more potentially avoidable inpatient admissions. The innovation improved access, reduced costs, and increased patient satisfaction.

2. Patients need support even when they aren't at the doctor's office.

Population health works only if hospitals and health systems can keep patients—particularly high-risk patients—engaged with their health care and can help them easily navigate the health care system, Ogundimu said. To that end, progressive providers are making investments in ensuring patients have on-demand support.

For instance, Kaiser Permanente offers a menu of online and in-person health coaching resources to assist patients with issues such as depression, smoking cessation, and weight management. And Privia Medical Group helps manage asthma patients by sending proactive reminders via text to carry their inhalers when air quality is low.

3. Not all of a patient's health care needs show up on a traditional medical chart.

To address the social determinants of health, such as food and housing security, hospitals need to make investments both in services they provide directly and in ways to connect patients with community support, Ogundimu said.

In both cases, health care providers need to start by identifying patients in need—but that doesn't have to be complicated. For instance, nurses can use a two-question screening tool to identify patients that deal with food insecurity.

Some systems have seen major gains from their screening efforts. Since 2015, ProMedica has screened more than 30,000 patients for food insecurity, and its two food pharmacies have served more than 3,000 households. How does the system do it? Inpatients who are identified as food insecure are discharged with an emergency food supply and information on community resources, while outpatients are given a longer-term prescription for the system's food pharmacy.

Population health management: Learn more about evolving practices and care models

Allyson Vicars, Health Care IT Advisor

Join me for a webconference on Thursday, March 30, in which I'll highlight examples of the major components of the population health management (PHM) model; discuss innovative uses of telemedicine to serve PHM requirements; and offer a brief primer on IT support for bundled payments and their role in health care reform and cost reduction.

Register now


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