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What is Population Health?
• 2003 Dave Kindig MD the health outcomes of a group of individuals, including the distribution of such outcomes within the group
• Tension remains between defining this as a field of study of health vs maintaining health; for todays discussion this is a concept of health and how it is maintained and managed
Population Health ManagementIncludes
• Clinical case reports and managing major public health conditions (excess caloric intake
and lack of exercise leading to obesity in children)
Population Health Management
Outcomes assessment –concurrent eventleads to quality improvement by default
the discipline of data collectionsharp focus on prioritizationpatient satisfaction drives encounterEMR becomes an asset the ideal situation‐ efficiency follows
Population Health Management
• Care Coordination
Across specialties
Across professions
Across staff
Across time and space
Population Health Management
• Care coordination requires another paradigm
shift for physician providers:
PATIENT AND FAMILY CENTERED
CARE WILL MANDATE
GIVING UP ‐‐‐‐‐‐
Population Health Management
There is a central patient center concept that will be a challenge to all of us in the future
THE PATIENTS YOU SEE ARE NOT
YOUR OWN
Population Health Management
Collaboration theory: in tightly controlled
collaboration : expense and effort rise exponentially with the number of participants.
Loose coupling which allows flexibility of
thought and imagination without rigid
definition of roles leads to better problem
solving.
Population Health Management
The more who have input into the process,
the greater the likelihood of success.
It makes more sense to work together
rather than to compete.
Population Health Management
• Collaboration and consultation will need to
be concurrent and in one encounter for the
sake of patient safety, convenience, patient
satisfaction, and efficiency
WHAT DOES THAT MEAN?
Population Health Management
RESOURCE MANAGEMENT:Currently focused on patient encounterFuture will be much more:
‐ Family centered‐ Education will be priority for patient,family but also for provider and staff‐Primary resource is time not moneyand team building, team rounds, huddle and problem solving will be criticalto success
Population Health Management
Reality of our mobile society even in rural
Iowa is patients have multiple options for
their health care.
Nearly 70% of health care choices are made
by word of mouth.
Population Health Management
Provider incentives will drive the process
both financial and non‐financial
Population Health Management
• Health care quality will be and already is continuously measured against your own internal standards‐
but also against external transparent standards that will be in the public domain
Population Health Management
Return on investment will be much less directly financial and will be driven by
patient outcomes measured in quality, safety,
and patient and family satisfaction. This will
require increase skill in teaching, motivation,
and changing behavior which has at its heart
more sophisticated education for providers and staff (as well as patients).
Population Health Management
Every patient encounter should have an
element of teaching no matter what the patient’s presenting problem or where she is
seen or who sees her
Population Health Management
• Changing behavior in patients will requiremuch more intentionality and many more resources in the future (starting with education of providers)
• Co‐morbid psychiatric illness needs to be addressed in a new and innovative way forhealth management to have any chance of success in any specific patient.
Population Health Management
Skin in the game. There is minimal data or
research to determine what level of accountability should be required from the
population we serve.
Population Health Management
Chronic disease management requires anticipation and not reaction to the presentsituation. An example is euglycemia in thehospital. Another is medicine reconciliation
How are we going to deal with access? An example is the ADA suggestion children with type 1 diabetes on pumps need 24 hour immediate access to professional help. Other potential hot spots: CHF, COPD, Cancer patients, DM,post surgical patients.
Why Transformation Efforts May Fail
• No sense of urgency
• Guiding coalition of leaders not empowered
to make change
• Vision lacking
• Under‐communication
• Not getting rid of known obstacles
• Not planning for short term wins (win/win)
Population Health Management
• Embracing health care change and improving
public health will require best practices that
improve patient health and increase
productivity. This necessitates options that
allow physicians to choose models that fit
their mode of practice.
Population Health Management
• Our journey to excellence will require all of this and more and will only be a success withengaged physicians. What will you and yourphysician group bring to the table?
PS• As I spent a couple nights doing this my spouse asks “ are you putting self care in thistalk?” Yes Rachel I am.