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Conference Highlight

Revolutionizing Population Health Approaches, Coordination in Health Care Setting


October 03, 2019

Nancy Myers, PhD, vice president at the American Hospital Association Center for Health Innovation, and James Dom Dera, MD, FAAFP, population health medical director at NewHealth Collaborative/Summa Health, recently spoke at Health Care Quality Congress 2019. Together they discussed care coordination in the health care setting and provided practical applications for both primary care and health systems.

At the beginning of the session, Dr Myers said that although health care has always been a team, a different team is needed that is well coordinated. She explained that population health is the health outcomes of a group that include the distribution of such outcomes within the group. She said that it is important to pay attention to the person who is directly in front of you in terms of population health. There are different patterns of needs she said, as well as outcomes.

According to the presentation, there are 4 parts that create the pathways to population health.

“We’ve divided it into 4 portfolios,” Dr Myers said.

They include:

  • Portfolio 1: Physical and/or mental health;
  • Portfolio 2: Social and/or spiritual well-being;
  • Portfolio 3: Community health well-being; and,
  • Portfolio 4: Communities of solutions.

The presentation also focused on the evolving primary care environment. They explained that primary care is associated with higher quality care, and lower cost of care.

“Primary care is associated with improved patient experience of care,” Dr Dome Dera said.  

He said that everyone has a vested interest in care coordination. All of the interest is geared towards to triple aim: high quality; lower cost; improved patient satisfaction.

“One of the most important things primary care practices can do is risk stratify,” Dr Dom Dera said.

According to the session, higher risk patients require more care coordination. He said it is important to identify higher risk patients and wrap resources around them.

“Care coordination is critical for higher risk patients.”

Dr Dom Dera explained that it is important to use risk scores to guide therapy.

“The goal of risk stratification is to manage patients based on their clinical need, using their risk score.”

“In general, the risk score is proportional to resource utilization.”

He noted that higher risk level requires more resources.

Dr Dom Dera then asked a handful of “What if” questions, including:

  • What if patients could see be seen when they needed to be seen?
  • What if primary care providers clearly asked the specialists what’s needed of the consult?
  • What if specialists answered the question and clearly spelled out next steps?
  • What if everyone knows what’s going on because all relevant information is shared?

Based on these questions, he highlighted the importance of care coordination agreements. He suggests having the format of a contract between two parties. Further, he said it is important to spell out expectations between PCPs and specialists who are part of the agreement.

“By themselves, care coordination contracts don’t do anything to foster a culture of coordination,” he said.

“Successful care coordination requires a culture change.”

According to Dr Dom Dera, process redesign, patient engagement, staff education, and partnering all go into and make up the culture.

He then briefly highlighted behavioral health integration models and social determinants of health. He told the audience that “we can all agree these are important factors.”

“So how are all of these tied together—social determinants of health, behavioral health integration, and care coordination?”

He explained that the more complex patient case, the more likely that all of these models will overlap.

At the end of the presentation they discussed “how health plans can integrate care to support members.”

According to the presenters, shared foundations are important. Health plans can utilize actionable information for care coordination, use data analytics to identify and track at risk patients, integrate care coordination support, and use support of community partnerships and referral processes.

Julie Gould

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