Measure, Monitor and Manage.

Population health management prevents illness by improving wellness.

Population health management (PHM) might not be a household word--but its potential for changing lives is enormous. While traditional fee-for-service healthcare has focused on treating illness in the individual patient, the influence of managed care and health maintenance organizations has produced a shift in focus to population health management.

PHM relies heavily on data collection and information systems, and focuses on the health of an entire population as a way to improve individual health. Using a systematic evidence-based approach, PHM identifies individuals who need care or are at high risk for illness, enrolls them in monitored health management programs and then measures the effectiveness of these programs.

In the past, healthcare organizations have found it hard to implement and measure PHM programs because they were unable to integrate numerous data sources from their legacy computer systems into a single data repository system. Technology has changed that, and in particular, Internet technologies have enabled many more PHM efforts. Today, organizations often use application service providers (ASPs) in their PHM efforts. ASPs can drastically decrease the time and resources needed to implement and manage PHM programs.

The advantage of PHM programs is their ability to provide valuable feedback to individuals on an ongoing basis, encouraging individuals to either change their negative behavior or continue their positive behavior, in the interest of better health. Nevertheless, the process of identifying individuals who need care or behavioral change, then tracking them and measuring their progress, still carries significant challenges. That said, here are several steps for optimizing the health of individuals with examples of organizations using PHM programs.

Risk Identification

The first step is to identify prospects for PHM. Each individual should be surveyed to determine his or her wellness level; then, those who can benefit from a specific health management program must be identified. It's best to use a dynamic health risk appraisal that identifies behaviors, medical and family histories, health habits, life experiences, clinical and fitness measures, and demographics. Survey results should provide staff with enough information to stratify the risk and develop health management programs based on individual and population needs.

At John Deere Health Plan, Inc., newly enrolled Medicare + Choice Secure Plus members complete a profile and a screening questionnaire to determine the probability of repeated admission, licensed from the University of Minnesota. The profile identifies members at risk for certain diseases who would benefit from participating in a health management program and also identifies members who should be offered preventive services.

Each member receives a customized report that contains healthy behavior scores plus information on exercise, safety, weight, nutrition, prevention and family history risks. Each member's physician also receives a detailed summary of the survey. Case managers will have quick and easy access to the real-time data, providing data integration for John Deere Health Plan's management programs.

A community-based healthcare organization can use the information from the risk assessment to help determine staffing levels and resources required to meet the needs of the population. For instance, if the survey results show a significant segment of the population is at risk for cardiac disease, additional cardiologists and other cardiac medical personnel may be needed to care for this population. By conducting regular risk assessments, healthcare organizations can spot trends and use that information for forecasting.

Types of Programs

Many organizations already have existing PHM programs in place. If not, it's wise to start small, selecting a few programs and then expanding as resources and time permit. Some of the most common types of programs are:

* Chronic diseases, such as congestive heart failure, asthma, diabetes and hypertension 

* Prevalent conditions, such as high-risk pregnancy, depression and osteoporosis 

* Preventive services, such as immunizations, pap smears and mammograms

* Healthy behavior programs, such as weight management, exercise and smoking cessation.

Start by assessing current practice relative to existing clinical guidelines and identifying key process and outcome indicators. Identify opportunities for improvement using the baseline risk assessment information and adapt the guidelines to fit the needs of the organization. Finally, develop and implement the program using tools for patients and staff, such as reminder systems, staff training, and provider and patient education materials.

Successful programs include ongoing participation by the healthcare organization staff as well as the individual. A program that encourages individual involvement, supported with up-to-date information and willing staff participation, can be the determining factor between a program in which individuals eagerly participate and achieve demonstrable improvements and one for which individuals show little enthusiasm and even less progress.

Design Your PHM Program

Well-designed health management programs display the following qualities:

* The ability to track enrollment and compliance

* Links to evidenced-based guidelines

* Involvement of individuals through incentives and regular feedback on their progress

* Surveys and measures that are completed initially for baseline information and then repeated on a regular basis to show a change in outcomes

* The ability to integrate the risk data with the program data for outcomes measurement

* Knowledgeable staff that can analyze and evaluate the data.

A cardiac rehabilitation software application, PhDx HeartFitRx[R] from PhDx e-SYSTEMS, Albuquerque, NM, used in South Carolina at Greenville Hospital System's HeartLife[R] program, manages patients' clinical, health and behavioral outcomes in a paperless network involving multiple sites and program components.

Greenville staff has the ability to collect, report and track patients, populations, programs, activities and medical history using the software application. Patients complete several surveys, establishing a baseline for future progress. HealthLog kiosks at the cardiac rehabilitation centers collect daily exercise and program information, giving patients instant feedback on their goals. The software also tracks patients through the cardiac rehabilitation outpatient phases.

Outcomes Measurement

It is important to create a system for regularly measuring and improving outcomes. Traditionally, measuring a program's progress was difficult because of the lack of effective systems to track and analyze the information. An ASP can eliminate these impediments to data collection and can provide real-time information and reporting capabilities that allow an organization to gauge the value of its programs.

It is important to measure all targeted individuals regardless of their participation. Tracking all individuals through the program--whether it is sending reminder e-mails to complete a survey or a telephone call reminder for a visit to the physician--is what differentiates PHM from individual care. Create goals for individuals and the targeted population, evaluate the outcomes regularly, and consider making improvements if warranted. Balanced outcomes measurement should cover four important areas:

* Health status studies, such as the SF-12TM and SF-36[TM] health surveys, as well as the Duke Activity Status Index (DASI)

* Patient satisfaction studies (industry and customer-specific instruments)

* Clinical outcomes

* Cost marker data, such as hospital length of stay, surgeries and visits.

For HeartLife, Greenville staff can access more than 30 standard reports with an option to create customized query reports. For the past 20 years, Greenville has collected program information on more than 4,000 participants in the program. This information was integrated into PhDx's database and will be used for population outcomes reporting.

PHM makes clinical and economic sense right now; and consumer empowerment, at-risk contracts, accreditation, Internet technology and cost containment are forces that will continue to fuel PHM's growth.

Margaret J. Gunter, Ph.D., is vice president and executive director of the Lovelace Clinical Foundation, Albuquerque, NM, a non-profit health research institute. She is also a PhDx e-SYSTEMS advisor.