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Among the many tenets of health reform is holding clinicians responsible for the health and health care costs of a population of patients.
It sounds simple. But "population health management" (PHM) is not the way health care traditionally has been provided. For decades, health care has been organized around episodic interactions with patients. PHM organizes care around patient health needs regardless of whether they are seeking health care. So PHM requires some changes in how care is organized and delivered; how populations are identified and patients are engaged; and how success is measured. The goal is better health for patients - including a more organized and coordinated patient experience and improved outcomes - with the allied goal of lower costs.
"It's really about ensuring that we are building a system that enables us to proactively address the health needs of a population," said Timothy Ferris, MD, who leads the PHM effort at Partners.
The program's initial phase has three main components. The first two, taken together, have been dubbed "Partners in Care:"
Patient-Centered Medical Home (PCMH): reorganizing primary care practices to provide team-based, patient-centered care for primary care patients, with heightened focus on prevention, chronic disease management, and medically complex care. One example of this team's work is development of a dashboard to help practices assess whether they have all the building blocks in place for a PCMH.
High-Risk Care Management: supporting practices in providing robust care management - including better access, monitoring, and care coordination - to complex, chronically ill patients who have a Partners/PCHI PCP. The pilot started at MGH in 2006 and is being spread to all PHS primary care practices. About 20,000 patients have been identified as needing care management and already 39 percent of them have a care plan in place.
Information Technology: developing and disseminating the technology needed to improve workflow for clinicians and provide data and analysis for reporting and measuring success. For example, the claims data warehouse has been used to collect and organize data, and processes now are in place to identify high-risk and chronic-disease patients.
In Phase 2, Ferris and his team will add specialty care and patient engagement programs to their charge.
While the ultimate goal is managing the health of all patients who receive primary care through Partners, the current universe for PHM includes patients for whom Partners has risk-based, accountable-care contracts with payers. "That's approximately 500,000 patients," said Ferris, "including those in our Pioneer ACO with Medicare, Partners employees, and patients covered by Blue Cross and Tufts contracts. We know that care is better using population health management tactics, and having contracts that identify a target population and also include specific incentives to meet our goals helps us stay focused."