Population Health Management

The National Association of Community Health Centers (NACHC) Background embraces the definition of population health put forth by the National Quality Forum (NQF) as ‘the health of a population, including the here is a general distribution of health outcomes and disparities in the population.’1 consensus around Population health in this framework is focused on the group of T the need to focus individuals within a specific geopolitical area and recognizes that on healthier people and the health of a population is more than just the clinical aspects of communities, and better care and includes social, economic, environmental, and individual behavioral and genetic traits. PHM, on the other hand, is the and more affordable management of health and outcomes for subpopulations such as healthcare (the “Triple the population of patients served by a health center. This effort Aim”). Defining is frequently referred to in more recent literature as population population health is a medicine. The Institute for Healthcare Improvement defines first step toward creating population medicine as the ‘design, delivery, coordination, and payment of high-quality health care services to manage the “Triple systems that effectively Aim” for a population using the best resources we have available to manage the health of us within the health care system.’2 a population. Health Center: Call To Action This document defines As health centers embark on a journey to achieve the “Triple Aim”, population health and they need to determine to whom they hold themselves accountable. population health Given the health care system is a long way from having health management and information combined with information from such sources as social provides a conceptual service agencies, police records, air and water quality, real estate foreclosures, and other data that might provide insights into groups framework health centers of individuals with social risks that pose threats to health outcomes, can apply in moving where do health centers begin meaningful work toward population forward toward health? This journey can begin with PHM, or population medicine, Population Health and a health center’s focus on achieving the “Triple Aim” among its Management (PHM). population of patients.

1 National Quality Forum. Multistakeholder Input on a National Priority: Improving Population Health by Working with Communities – Action Guide 3.0. May 2016 DRAFT. 2 Niñon Lewis. “Populations, Population Health, and the Evolution of Population Management: Making Sense of the Terminology in US Health Care Today.” IHI Leadership Blog. 19 March 2014. Population Health Management

Action Steps Toward Population Health Management As health centers develop new care delivery structures, broadened collaborations, new payer arrangements, and expanded IT and data capabilities, certain foundational activities will be required in the path toward population health management. While there is no set framework for success, NACHC supports development in each of the below actions as critical components in a successful Population Health Management (PHM) approach to the “Triple Aim”.

Patient Centered Medical Risk-stratification Redeploy Staff in Home (PCMH) Recognition The unique population Support of Population 1PCMH Recognition 4 served by health centers 6 Health Management demonstrates core capability in necessitates stratification of Develop care teams in new ways creating a system of care upon patients based not only upon that coordinate care, link to social which the health and outcomes complex medical conditions but services, and proactively manage of a population can be effectively also social determinants of health (communication with high-risk managed and patients can be affecting outcomes. Minimally, patients at least every 90 days) more actively engaged. a health center can begin with whole person care. a simple stratification algorithm Patient Registry (multiple chronic conditions) Use Data to Manage Health centers need to but should move toward a risk Patient Populations 2 maintain a patient registry stratification process that accounts 7 Use dashboards and other that goes beyond the list of for social determinants of health. tools to monitor the health of each current patients and includes all provider’s panel and the population patients attributed to a practice. Annual Health Screenings as a whole. The patient registry should Improving upon clinical include, at a minimum, clinical and 5 measures and preventive Health/Community administrative data, including lab, screenings requires a system System Partnerships pharmacy, procedure codes, and of care designed to accomplish 8 and Communication diagnostic and screening results. these tasks. Health centers need Build partnerships and effective Over time, this system should to design care processes that communication channels with include, or link to, claims data. schedule patients for an annual health system entities (hospitals, health screening that incorporates specialists, public health agencies), Accountable Care all recommended preventive IT (networks, HIE), and social Each patient in the health screenings and an assessment service organizations (housing 3 center registry needs to be for social risk. This process can be food, transportation) including linked to a primary care provider rolled out over time, depending on sharing referrals and outcomes. or care team who is accountable patient population size, and should Include mechanisms for patients for organizing and delivering the begin with high-risk patients. to engage in communication and right care at the right time while care processes. avoiding unnecessary duplication of services and preventing medical errors.