1. Population Management The following module is designed as a basic overview of population management for providers of healthcare, particularly those in a patient-centered medical home. At the end of this module, the reader should be able to: – Define “population management” – Name 3 examples of successful population management strategies or programs – Outline 3 tools available to practices which may be used for population management of health conditions

2. What is Population Management? Factor 6: Care team members are trained in the concept of population management and proactively addressing needs of patients and families served by the practice. Population management is assessing and managing the health needs of a patient population such as defined groups of patients (e.g., patients with specific clinical conditions such as hypertension or diabetes, patients needing tests such as mammograms or immunizations). NCQA Patient-Centered Medical Home 2011 February 1, 2011

3. NCQA Certification Standards NCQA Patient-Centered Medical Home 2011 February 1, 2011

4. NCQA Certification Standards

6. What Evidence do we have that this approach works? J Rural Health. 2003 Fall;19(4):506-10. Promoting pneumococcal immunizations among rural Medicare beneficiaries using multiple strategies. Montana Department of Public Health and Human Services Am J Manag Care. 2012 Dec;18(12):821-9. Population-based breast cancer screening in a primary care network.

7. Evidence for patient-centered medical home effectiveness targets population management

8. Insurance companies have been involved in some form of population management for decades

9. Employer Incentives Grow Companies Increase Wellness Incentive Dollars Most U.S. companies planned to increase the dollar value of the incentives they offer employees to participate in health improvement programs in 2012, according to an employer survey by Fidelity Investments and the not-for-profit National Business Group on Health fielded Nov. 1-Dec. 30, 2011, among U.S. companies ranging in size from 1,000 to 100,000 employees.an employer survey Among the top findings from the survey: Almost three out of four companies (73 percent) used incentives to engage employees in health improvement programs. The average incentive value was $460. That figure has increased steadily from an average of $430 in 2010 and $260 in 2009. Employers used different types of incentives, including cash, gift cards and contributions to health savings accounts. Program costs. Incentives aside, employers spent on average $169 per employee on health improvement programs in 2011, up from $154 in 2010 and $108 in 2009. Most popular offerings. Smoking cessation and employee assistance programs (EAPs) were the most prevalent lifestyle management offerings in the workplace.

11. Using the electronic health record to assess diabetes data

12. Tools for Population Management Databases: registries, electronic medical record Personnel: Nursing, PharmD, Physicians, MSW, Registration, Data experts, Statisticians, Researchers Electronic Medical Record Standing orders for preventive care Nurse Case Management – targeting high risk patients with chronic disease

13. What resources are needed to begin a population management program? Agenda Goals Demonstrated programs which are effective Time/money/people

14. Questions I have read each slide in this module and understood its content – True – False