5 steps to staging and integrating a population health program

As our healthcare system moves from focusing primarily on the diagnosis and treatment of acute disease toward a better balance between managing both acute and chronic disease and maintaining the health and wellbeing of defined populations, it is imperative that healthcare organizations make the planning process of building a population health infrastructure a strategic priority.

The following represents an outline of the fundamental building blocks of a population health program and presents a recommended approach to staging the transition from a sickness-based to a chronic disease/health-based business model.

I. Align with key strategic partners and stakeholders

The foundation of any population health program is to create strategic alliances with all major care givers and stakeholders through the creation of “at-risk” contracts will all major players. This begins with the physician staff as physicians and advanced practice practitioners must provide, lead and oversee all healthcare services. Alignment must also extend to: nursing homes, home healthcare, long term care facilities, skilled nursing facilities, telehealth platforms and any organization or service that has a significant impact on the delivery of healthcare services to a defined population. At-risk contracts ensure that all parties share the same clinical and business goals/objectives and can work together to ensure optimum outcomes.


II. Build a business/clinical intelligence health information exchange

It is impossible to manage the health of defined populations without real-time business and clinical information regarding the care that is both delivered and received. Thus, data must be converted into analytics through some kind of enterprise data warehouse that can collect all relevant business and clinical in real time and convert it to actionable information that is reported to anyone (including the patient) with a “need to know” and a “responsibility to manage.” Both management and healthcare providers must be able to perform interventions both in real time and (ideally) in anticipation of trends as they emerge. For instance, if a diabetic’s hemoglobin A1C is increasing, a clinical intervention should be performed before the patient develops diabetic related complications and is forced to seek more complex and costly care in more acute settings.

III. Implement a comprehensive palliative care and inpatient disease management program

The lowest hanging fruit in both a fee-for-service and capitated system is the 1 percent of Medicare beneficiaries who make up 21 percent of Medicare costs and have potentially life-threatening illnesses or injuries. A classic example is the elderly patient with a terminal disease. Data has demonstrated that the best outcomes and cost savings arise when palliative care is implemented as early as possible. For instance, if a child is diagnosed with cystic fibrosis (a potentially fatal disease that when treated effectively can become a chronic disease that can be successfully managed over time), palliative care should be implemented urgently to ensure the best possible and cost-effective outcome.

IV. Build new innovative sources of revenue

Technology and capital investment create new ways of delivering healthcare services in more innovative and cost-effective ways, and these include retail medicine and e-health. E-Health platforms currently serve more than 100 million Americans (almost a third of our population) and will only continue to grow and expand. Like other disruptive innovations, it may not be as good as seeing a physician in his/her office; however, it is certainly more convenient, accessible, cost-effective and for the majority of uncomplicated clinical conditions, pragmatic. Retail medicine focuses on the use of advanced practice practitioners who follow strict algorithms in lower-cost retail settings for narrowly defined high volume/low-risk clinical conditions. All healthcare systems can broaden their definition of healthcare delivery to include these models in their strategic plans for population health.

V. Implement a comprehensive outpatient disease management program that includes post-acute and home health care

As our healthcare system moves further away from fee-for-service toward a more capitated model, it is important to significantly reduce: hospitalizations, visits to the emergency department and physician office, and the use of ancillary tests and elective procedures. Thus, outpatient disease management becomes a priority. Disease management involves the use of business/clinical analytics to both monitor patients in real time and to create predictive analytics with decision supports that enable anticipatory interventions, typically in the home setting through the use of wireless technology.

Each of these components will contribute toward an integrated population health program which, if implemented in coordination with a solid business plan, will provide significantly improvement outcomes at lower costs.

Jonathan H. Burroughs, M.D., is president and CEO of The Burroughs Healthcare Consulting Network. He's also a certified physician executive and a fellow of the American College of Physician Executives and the American College of Healthcare Executives.