As defined, Population health is the health outcomes of a group of individuals, including the distribution of such outcomes within the group. These groups are often geographic populations such as nations or communities, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group.
We at Zenith Technology Solutions have designed systems that work with your organization as you monitor populations in preparation for value based contracting. We can conduct assessments that review the following:
- Do you have a list of available community based resources to help you manage the social problems facing the patient?
- Do you have a stable care delivery system?
- Are you financially stable?
- Are you adequately staffed?
- Can you engage patients in care?
- Have you managed patients with chronic diseases or high utilizers/high cost patients in the past?
- Have you coordinated care in the past?
- Do you have a standard on care in place?
- Do you have integrated behavioral health and primary care?
- Is your organization linguistically and culturally competent.
Based on these answers you can determine whether your organization is ready for full risk.
In developing a good population health management program, a key component is the engagement of patients. Engaging patients in care has been shown to lead to improved health outcomes and decreased costs. The use of technology as a tool makes engagement easier. “Whatever it takes to: Improve understanding; Improve communication; Improve delivery; Improve consumption, retention, and compliance.”
A health center in New York decided to review their population management of Diabetic patients in preparation for value based contracting with their managed care partners. Using a population health management software, they were able to identify their diabetic population and risk stratify them based on the diabetics’ risks for hospitalization.
Given their large number of patients identified and the need to work quickly, they narrowed their focus to deal with a small number of high risk diabetics who had hemoglobin A1C of greater than 9. With the help of Zenith Technology Solutions, they created a registry and developed a workflow to engage the patient in care. Care managers were trained by the ZTS team on engaging patients in care and ideas for goal setting with the patients.
Of the persons identified to receive intervention, 100% were contacted. 18% of the patients refused participation. 81% of the patients agreed to participate. Each patient identified a significant goal they were going to pursue over the course of six months to decrease the HgbA1C.
The average HgbA1C was 11.9. All patients were tracked and re-tested. The final average HgbA1C was 9.7, resulting in a drop 2.2. The number of patients who improved their A1C with this minimal intervention was 50%.