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A Population Health Guide for Primary Care Models

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A Population Health Guide for Primary Care Models IMPLEMENTATION AND EVALUATION: A Population Health Guide for Primary Care Models OCTOBER 2012 Care Continuum Alliance 701 Pennsylvania Ave. N.W., Suite 700 Washington, D.C. 20004-2694 (202) 737-5980 [email protected] www.carecontinuumalliance.org © Copyright 2012 by Care Continuum Alliance, Inc. All Rights Reserved. No part of the material protected by this copyright notice may be reported or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission from the copyright owner. CARE CONTINUUM ALLIANCE • Implementation and Evaluation: A Population Health Guide for Primary Care Models 2 EXECUtiVE SUMMARY Why Was This Guide Developed? This Implementation and Evaluation Guide (I&E Guide) was developed by the Care Continuum Alliance to inform and guide the implementation of key components of population health and specific strategies and suggestions for primary care-centered models to embed the components into their practice. In addition, this Guide offers suggestions and resources on measuring the impact of these efforts from both a cost and a quality perspective. The Guide also offers recommendations for population health implementation for a variety of models and recognizes that models vary widely by the resources available, the culture of the practice, organization or group of organizations working together, and their level of health information technology sophistication. Ultimately, any health care delivery model that is centered around primary care can benefit from the information delivered in this Guide. What Are the Goals of This Guide? The goal of this Guide is to offer education and guidance on the development and measurement of population health strategies embedded into the framework of a primary care-centered models. This Guide focuses on the overall value of population health strategies for primary care and how these strategies could be both implemented and measured based on the level of sophistication of the model. This Guide is intended as a resource for primary care-centered models regardless of where they are in the transformation process and offers suggestions and insight into specific tactics that can be utilized by any practice at both the clinician level as well as the organization level. Who Is This Guide For? This Guide is for any health care entity working towards a patient-centered population health model of care. It can also be useful for individual primary care and multispecialty practices that are transforming into a model of care that is whole-patient, whole-population focused. Models that may find the information and considerations in this Guide especially useful would include: • Integrated delivery systems, • Accountable care organizations, • Patient-centered medical homes, • Primary care practices, • Multispecialty practices, • Community health collaboratives, • State health exchanges, and • Large hospital systems. At the end of this Guide is a reference section with tools and resources that offer additional detail on several of the topics discussed within the Guide itself. In addition, we have included general resources in this section that readers will also find useful. CARE CONTINUUM ALLIANCE • Implementation and Evaluation: A Population Health Guide for Primary Care Models 3 HOW TO Use This GUide As a resource and tool for primary care practices interested in implementing population health, this Guide can be read in its entirety for an indepth overview of the value and benefits of population health. Each section can also be a stand-alone resource on very specific pieces of population health, including the value of the process, implementation, and evaluation. The following table lists specific topics that each section covers. Section Selected Topics Page Number Population Health What are the key components of population health? 9 Overview As a clinician or practice manager, what are the 14 objectives and the benefits of population health? What are the key benefits of population health for my 15 patients? How can I implement population health based on my own 18 needs and resources? Areas of Impact What kinds of impacts can population health have on my 19 practice or model of care? What is the value proposition for each of the components 21 of population health? What types of data should I consider if I am assessing the 24 health of my patient population? Why should I go through the process of risk stratifying my 21 patient population? What are some strategies that I can use to engage my 27 patients in their care? Can population health help me to better coordinate the 28 care that patients receive? What should I think about when I am trying to measure 33 savings of my population health efforts? What is a comparison group, and why is it important in an 36 evaluation process? What are leading and lagging indicators, and how will they 39 help me improve quality for my patients? CARE CONTINUUM ALLIANCE • Implementation and Evaluation: A Population Health Guide for Primary Care Models 4 TABLE OF COntents Foreword ...............................................................................................................................................6 Acknowledgments ................................................................................................................................7 Population Health Overview .................................................................................................................9 Best Practices Framework ..............................................................................................................13 Areas of Impact .....................................................................................................................................19 Impacts Model ................................................................................................................................19 The Value Proposition ....................................................................................................................21 Drivers of Change and Patient Engagement .................................................................................25 Care Coordination ..........................................................................................................................28 Measuring Savings ..........................................................................................................................33 Appendix: Special Topics .................................................................................................................... 43 Medicaid and Underserved Populations........................................... Release Date: December 2012 Oncology ........................................................................................... Release Date: December 2012 Reference A – Health Information Technology Framework .................................................................44 Reference B – Population Health Management Program Evaluation ..................................................46 Methodological Considerations Reference C – Evaluation Study Design Considerations .....................................................................54 Reference D – Methods to Define Outliers .........................................................................................55 Reference E – Evaluation Considerations for Small Populations .........................................................56 Reference F – Utilization Measures ......................................................................................................59 Reference G – Self Management Measures .........................................................................................61 Reference H – Medication Adherence Measures ................................................................................63 Reference I – Productivity Measure .....................................................................................................74 Reference J – Selection Criteria Considerations ..................................................................................76 Reference K – Additional Resources ....................................................................................................81 References .............................................................................................................................................82 Figures and Tables Figure 1, Population Health Conceptual Framework .....................................................................9 Figure 2, Population Health Process Model ...................................................................................12 Figure 3, Population Health Impacts Model ..................................................................................20 Figure 4, Population Levers for Change .........................................................................................26 Figure 5, Engagement Strategies Wheel .......................................................................................27 Figure 6, PHM Impacts on Care Coordination ..............................................................................29 Figure 7, Disease Progression Chart ..............................................................................................39 Figure 8, Leading and Lagging Indicators .....................................................................................42
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