1. Population Management
November 2017

2. Take home points Quadruple Aim is the goal
Primary care is vital to achieving these aims
Empanelment, Panel Management, Health Coaching and High Risk Care Management are effective strategies for practice-based population management

3. Objectives Outline the concept of population management.
Understand the fundamentals of empanelment and risk stratification. 
Describe methods to initiate and sustain practice based population management. 
Walk away with one idea to try out in your clinic.

5. Population Health Contributors
From: RWJ

6. Population management 101
What is it?
“the technical field of endeavor which utilizes a variety of individual, organizational and cultural interventions to help improve the morbidity patterns (i.e., the illness and injury burden) and the health care use behavior of defined populations”
For a primary care doc it’s about improving the big picture while staying focused on the individual

7. Population management 101
What is it?
“The science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals.”
CEA Winslow – an original definition of public health
“the technical field of endeavor which utilizes a variety of individual, organizational and cultural interventions to help improve the morbidity patterns (i.e., the illness and injury burden) and the health care use behavior of defined populations”
For a primary care doc it’s about improving the big picture while staying focused on the individual

8. The Big Picture
What is the population management trying to achieve?

9. System designs that simultaneously improve three dimensions:
Improving the health of the populations
Improving the patient experience of care (including quality and satisfaction)
Reducing per capita cost of health care

10. System designs that simultaneously improve three four dimensions:
Improving the health of the populations
Improving the patient experience of care (including quality and satisfaction)
Reducing per capita cost of health care
Care team well-being

11. Population management
So where does population management fit into primary care?

12. It is one of the key building blocks of the PCMH
Bodenheimer, et al. Annals of Family Medicine. 2014

13. Population management
Practice-based strategies:
Empanelment
Panel management
High risk care management
Health coaching (for another time)
Today we’ll focus on panel management
Bodenheimer, et al. Annals of Family Medicine. 2014

14. Empanelment
Who are our patients?

15. Empanelment
A process of linking each patient to a care team and a primary care clinician
A deliberate attempt to identify the group of patients for whom a clinician or team is responsible

16. Importance of Empanelment
Establishing which patients are assigned to which physicians is important
It makes patients happier
It defines the workload
Helps predict patient demand
Necessary to measure provider performance
Improves outcomes

17. Defining Clinic Populations
Two Approaches:
Community-wide population: Working in a defined geographic area to accomplish the Triple Aim for a community
Defined population: A population that makes business sense around the Triple Aim
Defined population is most relevant to UPI and other health systems.
Business sense = sustainability.

18. Tools to help
Patient panel size worksheet can be found here:
More on our Resource Hub:
resourcehub.practiceinnovationco.org/search/empanelment

19. *Not All Panels Are Equal
Sex, age, illness burden, and socioeconomic status all can affect the “demand” of a panel on providers, teams, and clinics
With even basic data (sex, age, visit numbers) a clinic can adjust panels more accurately
More sophisticated systems can utilize more complicated factors like multi-morbidity, mental health, social determinants

20. Practice Reflections
Who in the office is responsible for it? When does it get done? How is this information used in your clinic for operations and QI?
Challenges you have faced when it does not get done properly.
Audience questions. I may use these as prompts if the audience does not have questions:
Is there an ideal panel size you shoot for? What do you do to fill up panels or shrink them?
Do you work on distributing patient types (kids, adults, m/f, high risk, etc.)?

21. Questions on Empanelment?
Audience questions. I may use these as prompts if the audience does not have questions:
Is there an ideal panel size you shoot for? What do you do to fill up panels or shrink them?
Do you work on distributing patient types (kids, adults, m/f, high risk, etc.)?

22. Panel Management
Once you have a list of patients, what do you do with it?

23. Registries Gaps In Care +Team Based Workflows Panel Management

24. Registries Can focus on particular subpopulations
Disease specific (ie DM, HTN)
Prevention (ie immunizations, cancer screenings)
Utilization (ie Frequent ER users, recent discharges)

25. Registries Can focus on particular subpopulations Or panel-wide
Disease specific (ie DM, HTN)
Prevention (ie immunizations, cancer screenings)
Utilization (ie Frequent ER users, recent discharges)
Or panel-wide
Key indicators and needed services for all empaneled patients

26. Registries
Lumping patients with similar needs to streamline work and evaluate outcomes
Start with the basics, advance to predictive risk stratification
Subpopulation vs. Intervention – which comes first?

27. Gaps In Care
Goal is to perform all recommended services for a patient regardless of their reason for visit
Can be carried out at the point of care or through asynchronous communications

28. Registries alone don’t improve care. Teams do!
Team based workflows
Registries alone don’t improve care. Teams do!

29. Practice Reflections Panel reflections
Include how you choose the patients, who does the work, any metrics you track to see that you are making progress
Associates – DM outreach using A1C; closing gaps of care during flu visits
AFW – MA workflows and protocols; ambulatory health promotion
Audience questions
How did your teams pick these populations to focus on?
How did you engage your teams to participate?
Clinic vs health system – pros and cons?

30. Questions on Panel Management?

31. High Risk Care Management

32. Why Target Complex Patients
Kyle
What’s the big deal about complex patients?
Why are people focusing on this now?

33. of patients account for 50% of Costs
Top 5%
of patients account for
50% of Costs
Kyle
Allows clinic to focus on those in most need
Prioritize resources
Structure interventions

34. Another way to demonstrate the same idea.
Kyle
Another way to demonstrate the same idea.
This also shows that the high cost patients are becoming even more expensive.
Haas, et al. American Journal of Managed Care. Sep2013, Vol. 19 Issue 9, p725-a p.

35. Who are the 5% ? Most Intense Intense Moderate
- Homeless, Schizophrenia, etc
Intense
Multiple unstable chronic illnesses
Depression + anything else
High Utilization
- Other issues (frail, social, financial, etc.)
Moderate
Well compensated multiple diseases
Single diseases
Bio-psycho-socially stable
Kyle

36. Identification Methods
Thresholds – Certain number of visits or medications or biomarkers
Algorithms – combinations of diagnoses or assessment results
Provider identification – just ask the clinicians

37. Developing a complex care management system
Summary:
Define the business case
Determine outcomes for success
Identify and stratify patients
Develop model of care delivery
Structure care management services
Enroll patients
Learn, adapt, grow
More on our website at:

38. Practice Reflections Panel reflections
Include how you chose these groups to intervene on; how you find the patients (is it something in the EHR, some prompt from the hospital, provider input, etc); who on your team is involved; how much time to you give the team to do the work? metrics of success;
Associates – transitions of care from ER, polypharmacy, social determinants
AFW – TOC from hospital, complexity index, social determinants

39. Questions on high risk care management?

40. Wrap up
Panel suggestions

41. Practice Reflections
In closing, what are your suggestions to practices that aren’t doing any of this – knowing what you know now, where would you start?

42. Take home points Quadruple Aim is the goal
Primary care is vital to achieving these aims
Empanelment, Panel Management, Health Coaching and High Risk Care Management are effective strategies for practice-based population management

43. Resourcehub.PracticeInnovationCO.org