The Scalable Population Health Enterprise

Generating Clinical and Financial Returns from Cost-Effective Care Management

Explore five lessons on aligning care management resources across the continuum—the only way to leverage every ambulatory network asset, better allocate resources, and avoid duplication of effort.

To be a successful population health manager, your organization must deploy every piece of the care management enterprise effectively and efficiently.

Learn how to scale primary care staff resources, use virtual channels to manage populations over time, and engage patients beyond the clinic.

Why not use one care management model for all?

Every population health manager starts with a care management model focused on high-cost patients, the 5% of the population with poorly managed conditions and multiple comorbidities.

This approach—usually involving a one-to-one dedicated care manager—drives quick improvements in quality and total cost of care for high-risk patients but becomes impractical, expensive, and inefficient when health systems expand the care management model to their lower-risk populations.

To scale the enterprise in a way that meets the varied care needs of the entire patient population, health systems need a flexible model and a centralized care management infrastructure with clear leaders, defined goals, and aligned resources.

With this system-level view, population health leaders can leverage every ambulatory network asset for access, better allocate scarce and expensive resources, and centralize out-of-practice support to avoid duplicative efforts.

Four attributes of scaled enterprises

Systemized care management
The best population health managers build a centralized care management infrastructure to set goals and outline care standards across the network. A critical feature of this infrastructure is the ability to analyze and share data across the care management team in a timely and actionable way.

Shared resources across the ambulatory network
Looking at the ambulatory enterprise as a whole, rather than as individual practices, allows leaders to better resolve gaps in access or ongoing management. Systems can scale resources for social, behavioral, and specialist support across the network, rather than duplicate them at the practice level.

Centralized remote management
To scale beyond the primary care practice, population health managers build virtual platforms such as patient portals. These investments should prioritize features that reinforce the patient-care team partnership and make it easy for staff to respond in a timely fashion—two elements important to patient satisfaction and ongoing loyalty.

Proactive patient management
For a subset of patients, the care team needs more frequent updates on specific clinical metrics. In these cases, remote monitoring tools can be an effective way to identify patients in need of additional care team support and to quickly respond to changes in a patient’s health status. Community partnerships also can help systems proactively reach out to patients with unmet care needs.

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