Download presentation
Presentation is loading. Please wait.
Published byMyron Tyler Modified over 9 years ago
1
Population Management What is that and why do I need to know? Elisha Brownfield, MD
2
What is Population Management? 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).
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.
10
Population Management EHR enabled Change in mindset – who is not here and needs to be? Change in payment
11
University Internal Medicine (UIM) at MUSC Faculty practice = 6000 patients 14 faculty – most part time Resident practice = 6000 patients 96 residents on 1 month block rotations every 4 months Total visits = 38,000 per year
12
Demographics (n=9,933 patients) Age, y (mean ± SD) 58.6 ± 16.89 18-49, No. (%)2654 (26.72) 50-64, No. (%)3285 (33.07) 65-75, No. (%)2357 (23.73) 75+, No. (%)1637 (16.48) Male, No. (%)3669 (36.94) White, No. (%)4833 (50.88) Married, No. (%)4596 (46.20) UIM Patient Demographic
14
UIM: Overall MUSC ED, Hospital, rehospitalization over three years ED N of PTs Total # in 3+ yearsMeanMedianMinMax 1128420,7631.84 0 0222 HOSP_ALL N of PTs Total # in 3+ yearsMeanMedianMinMax 11284 9, 591 0.85 0 041 REHOSP w/in 30 days N of PTs Total # in 3+ yearsMeanMedianMinMax 112842,1440.190028
15
Obesity & CV risk HealthyHypertension Hyperlipidemia & Hypertension
16
Complex, CV disease & Depressed Chronic lung disease, Depression & CV risk Diabetes & CV risk Renal Disease, Depression, & CV risk
17
UIM patients: Multiple chronic conditions
18
12 Clusters and independent risk Largest number of patients was in the multiple chronic condition cluster (1512) Largest proportion of high-utilization patients was in the renal disease cluster (68%) RR=5.47 Visit adherence < 80% adherence dramatically increases ED and hospitalization risk RR= 1.33 Social determinants Zip codes with >25% of residents below poverty level RR=1.25 Dx: Sickle cell disease: 1% of population, 12% of utilization
19
Quality
20
Quality measures: A little team competition doesn’t hurt Resident practice Faculty practice
21
Hospitalizations 16% ED visits 25% Total ACSC Non-ACSC Inception cohort, interrupted time-series analysis Limited to MUSC utilization
22
UIM Tools for Population Management Database: Epic, DDI Personnel: Nursing, PharmD, Physicians, MSW, Registration, Data experts, Statisticians, Researchers Electronic Medical Record Standing orders Case Management
23
UIM Team Meeting Problem solving Short-term QI Hypertension Team Meeting – QI with large/color teams. Analyzing data Diabetes Team Meeting – one color team discussed each week x 4 months in large group. 320 patients: overall drop in A1C 9.84 % - 9.06% (p< 0.0001) Analyzing data Hospital Discharge Team Meetings – Teams broken up into Case Management small groups. Analysis on-going. New problems identified and resources being pursued (i.e. Psych involvement in UIM)
24
What do we need? Agenda Goals Demonstrated programs which are effective Time/money/people
Similar presentations
© 2025 SlidePlayer.com. Inc.
All rights reserved.