Population Health Management: Reorganizing How
Partners Cares for Patients
Among the 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":
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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.
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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.
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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."
How does population
health management (PHM) fit within the overall Partners Strategic Initiative?
-
At the Partners Annual Meeting in April,
President and CEO Gary Gottlieb, MD, said "We must lead the way in managing
populations, not only as a response to today's environment, but because it is
core to our mission."
PHM is a key piece of Partners
Care Redesign, which is focused as well on episodic specialty care; together
they are one of the three pillars of the Partners Strategic Initiative (along
with Patient Affordability and Reputation/Communication) in Phase 1
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PHM is a vehicle for delivering the
infrastructure (care management as a example) that supports enhanced care
delivery not paid for under a fee-for-service payment system.
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PHM coordinates with many aspects of the
Strategic Initiative, including employee health, readmissions, mental health,
palliative care, Partners eCare and
others.