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Population Health Management (PHM)

Posted on September 1, 2016 | Categories: Population Health Management | Posted by: admin

Population Health Management (PHM)


  • Population health has been defined as “the health outcomes of a group of individuals, to reduce health inequities due to factors i.e. Financial, Social, Physical or Genetics”. It is not just the overall health of a population but also includes the distribution of health
  • Population Health Management (PHM) is a gradual and necessary shift from Volume to Value Care or in other words Population health Management (PHM) delivers value-based care viz. from earlier Fee for Service model to now Fee for Outcome
  • Accountability, Outcome and Meaningful USE (AOM) for population health is a key premise driving the value-based care movement
  • PHM – Value-based care (VBC) requires a proactive approach, where at-risk populations are identified, tracked and handled differently for desired Outcome than historically has been the norm
  • PHM-VBC promotes Care Coordination across different parts of the health care system with ongoing patient outreach and interaction to bend the cost curve while achieving comparable or improved patient outcomes
  • Population Health Management initiatives can reduce readmissions, improve community healthcare outcomes, and increase revenues
  • PHM can help avoid hospital admission of a heart failure patient who could be effectively treated in an ambulatory manner thus delivering better care and cost curve
  • Population Health is a great tool for population / patients suffering from 5 chronic diseases like 1. Cancer 2. CHF (Health – Cardio Vascular) 3. Diabetes 4. Mental Health & 5. Hypertension (BP)
  • Four Pillars of PHM are 1. Understand Population 2. Manage Risks 3. Coordinate Care 4. Improve Quality to address and reduce the Health Inequalities Gap (HIG) amongst Healthy and Not -Healthy Population


Achieving Population Health and Real Challenges


  • Analytics are critically important for helping Payers & Provider understand how best to target their limited resources in order to maximize patient care and financial outcomes. just knowing that a patient is likely to be a high utilizer of services or a high-cost patient is insufficient if HealthCare firm can’t actually impact the care or outcomes in an appropriate manner
  • Drive patient engagement by integrating telemedicine, patient portals, HIE/HIX and mobile devices in the care continuum
  • Establish realistic metrics to measure success
  • Extracting EMR-based Clinical Data (not Claims Data alone) is a must for population analysis, for the depth and understanding of populations and Population Grouping based on Risks & Ailments
  • Identifying patients that are candidates for extra management
  • Many healthcare care coordinators are still using paper-based, manual processes, as well as juggling tasks and patient caseloads on spreadsheets and homemade databases. That said, Under Delivery System Reform and Incentive Payment (DSRIP) funding from Federal (CMS/HHS) & State are available to Hospital & Health Systems to invest in the Population Health Technology for managing their Population & Communities’ health
  • Organizations are hamstrung by limited data sets and incorrect information, thus combining Payer-Provider and EMR-Claims Data is the right way to achieve true PHM-VBC
  • Resource, Workflow, Pharmacy and IT infrastructure investments are essential for clinically integrated network to improve population health
  • While electronic medical records (EMRs) have increased access to patient information, interoperability challenges remain in sharing data across multiple EMR platforms


Analytics for Population Health Management (PHM)


  • Ability to predict at-risk patients to reduce preventable costs
  • Accurate data powered by integrated clinical and claims data across the continuum of care
  • Ability to track and compare performance outcomes via deep comparative clinical benchmarks


Population Health & Care Management

Population Health is a tool to achieve Care Management. Both delivers same outcome. The Tools are:

  • Care Coordination
  • Case Management
  • Discharge Management
  • Disease Management
  • Medication Therapy Management (MTM)
  • Mobile Health or Wearable Health
  • Tele-Health


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