Chronic illness isn’t inevitable, but certain factors make it far more likely. In population health management, health care organizations collect data from multiple sources to predict the risk of illness in different groups of patients. That way, providers can focus attention on groups, or populations, that are growing sicker instead of getting healthier. By using data tools to track and improve health outcomes, clinics and health care centers can lower costs while helping patients take charge of their health.
Research has shown, for example, that patients’ zip codes are a better predictor of health than their genetic code. With social determinants such as housing, food access and neighborhood safety driving 80 percent of health outcomes, there is a need to broaden the lens of population health management. By understanding the social, political, and cultural context in which patients and their families live, organizations can better provide whole person care.
But transitioning to population health management – or strengthening that approach – isn’t easy. It requires a host of new strategies, skills, care team members, workflows, and technology use. New care team need to be developed to focus on addressing gaps in care and managing chronic conditions. To provide more of a whole-person orientation, care teams also need to develop community partnerships to address social needs.
CCI’s Population Health Learning Network (PHLN) was designed to help safety net organizations make that transition. To do so, the network convened 25 safety net primary care organizations to learn, share, build, and refine care models and strategies over the course of two years. With funding from California Health Care Foundation, we developed this toolkit — a rich compilation of resources and strategies developed by participating organizations and faculty. We hope you find it a valuable tool in improving your own population health management.
What you’ll find in the toolkit
This toolkit provides resources and tools in the following areas:
- Value-Based Payment — Value-based payment arrangements are designed to hold health care providers accountable for the care they provide. This section provides resources to support organizations with changes that are central to moving from volume to value. Among other things, it addresses transforming care models, coordinating across teams, and getting buy-in from staff and stakeholders.
- Learning Organizations — “Learning organizations” use a systems approach to develop processes that support individual and team learning and improvement, including tools that blend human-centered design and quality improvement methodologies..
- Team-Based Care 2.0 — This section builds on the collaborative team concept by experimenting with and expanding care team roles and methods to promote cross-team communication.
- Strategies to Enhance Access — To create sufficient access, you need to understand your patient population and their needs, your community’s needs, and options for care that meet patients where they are. This section outlines strategies and technology to improve outreach, preventive services, availability, efficiency, and health outcomes. These include open-access scheduling.
- Behavioral Health Integration — This is an umbrella term for efforts to blend the delivery of physical, mental, and substance use disorder care. The goal is to understand a patient’s needs using a whole-person approach. This section examines various approaches to behavioral health integration and ways to leverage technology to support it.
- Care Management for Complex Patients — Care management is an umbrella term for support provided to patients and families in order to improve their health and reduce the likelihood that a condition may worsen. Resources are organized into two subsections of care management strategies and risk stratification.
- Social Needs — Social needs, also referred to as social determinants of health, are non-medical factors that impact a patients’ overall health and wellness. Resources in this section include building internal systems to identify social needs, developing effective partnerships with community-based organizations, and establishing referral processes to connect patients to resources.
- Data and Analytics — Effectively leveraging these data to drive business and clinical decision-making requires a group effort to align strategy in many areas: technology, analytics, business processes, workflows, and administration. The resources in this section include tools to assess an organization’s data and analytics and to use data to effectively drive organizational change.
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