Prescriptions for Excellence in Health Care Newsletter Supplement A collaboration between Jefferson School of Population Health and Eli Lilly and Company
Volume 1 Issue 8 Prescription for Excellence in Health Article 5 Care # 8 Spring 2010
Spring 2010
Care Coordination in the Context of a Population Health Management Model
Tracey Moorhead DMAA: The Care Continuum Alliance
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Recommended Citation Moorhead, Tracey (2010) "Care Coordination in the Context of a Population Health Management Model," Prescriptions for Excellence in Health Care Newsletter Supplement: Vol. 1 : Iss. 8 , Article 5. Available at: https://jdc.jefferson.edu/pehc/vol1/iss8/5
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A collaboration between Jefferson School of Population Health and Lilly USA, LLC
Editor-in-Chief: David B. Nash, MD, MBA • Managing Editor: Janice L. Clarke, RN, BBA • Editorial Staff: Deborah C. Meiris, Alexis Skoufalos, EdD
Care Coordination in the Context of a Population Health Management Model By Tracey Moorhead
Population health management targeted interventions and services to engendered by wellness, disease, and encompasses a broad continuum of care individuals who are well, at-risk, or chronic care management programs. services, from wellness and prevention managing 1 or more chronic conditions. through disease management and The convergence of these roles, resources, complex case management. This The expansion of services to encompass and capabilities in the population health continuum of care represents the a full continuum of care, along with improvement model ensures higher evolution of the traditional disease the dramatic expansion of population levels of quality and satisfaction with management industry from one focused health management providers, care delivery. Further, coordination on managing single chronic conditions highlights the importance of careful and integration are important tools to to one focused on managing multiple coordination of services and providers. address health care workforce shortages, comorbidities. It recognizes that early With the evolution from single-state individual access to coverage and care, intervention can keep healthy people disease management to population and affordability of care. well, help those who are at risk stave off health management strategies, the the development of chronic conditions, focus is on techniques and tools for Accountability must be assigned for and educate those with chronic improved care coordination. delivering and coordinating appropriate illnesses about condition management cost-effective care. Likewise, the techniques to mitigate complications Population Health Management Model achievement of targeted improvement and exacerbations. On behalf of the population health and goals for population health must be management industry, DMAA: The explicitly recognized and proportionately DMAA: The Care Continuum Alliance Care Continuum Alliance advances a rewarded. To this end, the population provides services along all points of population health improvement model health improvement model envisions this continuum - from wellness to that contains the elements of a fully- optimizing physician office practices and population health management to connected health care system to provide other services that improve population disease management - via its member all members of the health care team health and add value. To best achieve organizations, which include health plans, with essential tools to ensure proactive, this, payers, purchasers, patients and labor unions, employer organizations, coordinated, quality health care. The their advocates, and other members pharmaceutical manufacturers, population health improvement model of the health care team must promote pharmacy benefit managers, health highlights 3 components: and ensure appropriate reimbursement information technology innovators schedules for cognitive services, care and device manufacturers, physician • the central care delivery and leadership coordination, referral activities, and groups, hospitals and hospital systems, roles of the primary care physician; adherence to desired processes such as the use of evidence-based clinical guidelines. and academicians. These diverse • the critical importance of patient organizations share DMAA’s vision of activation, involvement, and personal Key components of the population aligning all stakeholders to improve the responsibility; and health of populations. Members seek to health improvement model include: maintain and improve health care quality • the patient focus and capacity • population identification strategies and restrain health care costs by providing for increased care coordination and processes;
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• comprehensive assessments of care coordination, and by addressing centered, high-value care is among physical, psychological, economic, cultural sensitivities and preferences of these priorities and associated quality and environmental needs; individuals from disparate backgrounds. goals include improved communication and medication management during • proactive health promotion programs Finally, the model promotes transitions in care and reductions in that increase awareness of the health care coordination by promoting 30-day readmissions and emergency risks associated with certain personal complementary care settings and department visits. behaviors and lifestyles; techniques, such as group visits, remote patient monitoring, telemedicine, The NQF defines “care coordination” • patient-centric health management telehealth, behavior modification, and as “a function that helps ensure that goals and education, which may motivation techniques, for appropriate the patient’s needs and preferences for include primary prevention, behavior patient populations. health services and information sharing modification programs, and support across people, functions, and sites are for concordance between the patient Accountable measurement of progress met over time. Coordination maximizes and the primary care provider; toward optimized population health the value of services delivered to patients should include various clinical indicators by facilitating beneficial, efficient, safe, • self-management interventions aimed including process and outcomes measures; high-quality patient experiences and at influencing the targeted population assessment of patient satisfaction improved health care outcomes.” to make behavioral changes; with health care; functional status and quality of life; economic and health care The NQF has designed 5 care • routine reporting and feedback loops, utilization indicators; and impact on coordination domains: 1) health care which may include communications known population health disparities. “home”; 2) proactive plan of care with patients, physicians, health plans, These indicators can demonstrate the and follow up; 3) communication; 4) and ancillary providers; effectiveness of coordination activities information systems; and 5) transitions and “handoffs.” The population health • evaluation of clinical, humanistic, and across services and providers. model encompasses these 5 domains to economic outcomes on an ongoing Care Coordination in Population Health achieve improved care coordination. basis with the goal of improving overall Management population health. As already described, population Summary The population health improvement health management is a system of The population health improvement model supports care coordination goals coordinated health care interventions model represents the evolution in a wide variety of ways. First and and communications for at-risk and of traditional, single disease state foremost, it encourages patients to have chronically ill populations. Population management by facilitating and ensuring a provider relationship whereby they health management supports care patient-focused care coordination to receive ongoing primary care in addition coordination by facilitating/supporting improve the quality of health care to specialty care, and complements integration across providers or care provided to individuals across the the physician/practitioner and patient settings to link chronically ill individuals continuum of care and services. The relationship and plan of care across all and their families with health education population health improvement model stages, including wellness, prevention, and appropriate services and resources. is closely aligned with the National chronic, acute, and end-of-life care. Care coordination also includes Priorities Partnership’s efforts to improve interrelationships across health care care coordination. Aligning the goals The model supports physicians by services and strategies, from primary and components of care coordination offering additional resources to address prevention and acute care to chronic offered by DMAA: The Care gaps in patient health care literacy, and end-of-life care. As such, care Continuum Alliance, the NQF, and the knowledge of the health care system, and coordination is a central component of National Priorities Partnership enables timeliness of treatment. It also provides population health management. the dissemination of a comprehensive technical assistance to physicians – from tool that all stakeholders can utilize as collecting, coordinating, and analyzing The National Priorities Partnership, they transition from single condition patient-specific information and data convened by the National Quality programs, created and delivered in a from patients and multiple members of Forum (NQF), has established 6 silo, to whole person, whole population the health care team to analyzing data key goals to transform health care health management. across entire patient populations. and create and expand world-class, patient-centered, affordable care by Tracey Moorhead is President and Chief Further, the model assists unpaid eliminating waste, harm, and disparities, Executive Officer of DMAA: The Care caregivers, such as family and friends, and thereby reducing disease burden. Continuum Alliance. She can be reached by providing relevant information and Care coordination to ensure patient- at: [email protected].
This newsletter was jointly developed and subject to editorial review by Jefferson School of Population Health and Lilly USA, LLC, and is supported through funding by Lilly USA, LLC.