5 Small Steps for Small Practices Starting Population Health Management

Population health management, or PHM for short, is quickly becoming the standard of care for healthcare organizations of all sizes.

This change has brought concern to many solo practitioners and small practices, as it takes several steps to become fully compliant. The technological changes PHM requires is only one part of the equation; it could affect many other areas of practice as well, such as monetary issues and staff concerns.

This may lead you to wonder if you’ll have to start from scratch, but you can stop wondering because the answer is “absolutely not.” When it comes to moving toward a population health model, there are many ways to use tools you already possess to get started.  

As we cover these please keep in mind that this change won’t happen overnight and that’s okay.     

1. Time for a Mindset Change

Everyone’s talking about mindsets these days and for good reason; it’s the first step to making a change. Being able to wrap your mind around the how and why not only makes change easier to handle, but makes you more likely to follow through as well.

The first step to moving toward a population health management system is realizing that for the model to work, a team approach is needed. As a physician, you’ll need to begin envisioning yourself as an important member of a larger care team, follow your patients closely and develop an eye for data.

2. Great Care Requires a Team

Physicians tend to feel solely responsible for each patient. By embracing the newer population health models, once created and implemented, you can rest assured that a team of talented healthcare professionals are working to provide the best care for your patients.

To be successful, you’ll have to collaborate with others. To begin, you can partner with other physicians and larger healthcare companies by joining independent physician associations (IPA) or clinically integrated networks (CIN). Membership in these partnerships can ease the transition to population health by increasing resources available to you and strengthening the possibility of access to larger systems.

Independent physician associations are business entities, owned by a group of independent physicians. The purpose and activities vary depending on the network but can be a great resource for those getting started with population health management.

“Front office staff can assist with the transition as well”, adds Shirley Orr, MHS, APRN, NEA-BC, Public Health Consultant and President of SOCO Consulting. As an example, “If you regularly see patients over 40, consider including the American Diabetes Association’s Type 2 Diabetes Risk Test with the other paperwork at the start of the visit. There are many similar quizzes that can serve as a starting point to collect useful information to get started with population health management.”

Those who work “behind the scenes” can also play a pivotal role. For example, coding and billing professionals can start to watch for specific codes that patients with certain conditions should be billed for each month/year. When they notice these aren’t being done, they can point it out to help ensure your patients are receiving the care they need on a regular basis.

3. Obtain Useful Data With Tools You Already Use   

You’re likely using the tools you need everyday, so a few tweeks to the data you’re collecting may be all you need to get started. The trick is to make sure the data is useful. Claims data, electronic health records, patient portals and other software you likely already use capture important pieces of data you need to move toward implementing your population health management program.

Claims Data

Known to be complete, well structured and standardized, claims data will help answer some of the most basic health population management questions. Useful information such as patient demographics, diagnostic codes, service dates and the cost of services help paint the picture of who your patients are, concerns they face and the cost of treating them.  

Electronic Health Record (EHR) Data

Data obtained from EHRs help fill in the gaps missing from claims data. The EHR contains small pieces of compelling clinical data that doesn’t always make it on the claims.  

EHRs house details like the type of care delivered, provider impressions, and other seemingly small - yet vital - information that patients tell providers during visits. Because this is information that doesn’t lead to a diagnosis it never ends up on the claim record. They also contain basic information such as vital signs, allergies, prescribed/OTC medications, imaging reports, lab data and immunization dates.

This data can provide answers to important population health  management questions, such as:  

• Which diabetic patients have had elevated A1C levels in the last 6 months?
• What patients are taking medications, prescribed by several physicians that need to be cross-checked for contraindication?
• Are pediatric patients receiving recommended vaccinations on schedule?
• Are there patterns in concerns from any group of patients with similar diseases?

Patient-Generated Health Data

Does your practice regularly send out satisfaction surveys? Have you adopted a patient portal system? Are you active on social media and receive feedback there? Do your patients use any type of wearable device that record data?

Any of these count as patient-generated health data and can be integrated into your population health management program. If you’re not currently using these tools, they would be a place to start collecting more data for your program.

4. Find Patterns and Implement Actionable Programs  

When collecting data from your tools, look for groups of patients who would benefit from combined intervention.  

For example, look at all your diabetic patients whose health continues to decline. Figure out how often these patients are being seen by you, other specialists, or in the emergency room, and for what reasons.

If you identify a pattern, consider making in-office educational materials, starting classes, office challenges, or other type of intervention to help the patients directly from your office.

For example, if you have a Facebook page, run a contest or present challenges to those who “like” or follow your page. Add an incentive in the form of some type of useful prize. People love challenges and will always engage if they see the value!

Shirley Orr also offers this advice regarding patients who require care outside your office: “For patients who require outside referrals, a warm hand-off to specialists or other interventions will have better results than simply handing them a piece of paper.”

5. Use Secure Email and SMS Technology

Many EHRs collect patient email addresses and some are even enabled for two-way SMS (text) messaging. These are ideal ways to communicate with patients and can be powerful tools. You can do anything from checking in with patients, to delivering educational courses, to reminding patients about important events, so put these tools to work!

As a form of patient education, consider setting up email courses to be delivered over time to patients whose schedules don’t allow coming into the office.

ok nFor example, come up with a five-day course to help get a diabetic patient on track with their eating schedule. You could send this to your diabetic patients and provide a valuable service that you can use over and over and doesn’t require them to do more than open an email, read your advice and hopefully put it to good use.

Hopefully these tips have shown you that moving toward population health management doesn’t need to be overwhelming. These ideas are just a few ways to use what you already have to get started toward creating a population health management system within your practice.