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The Human Side of Population Health Management

February 6, 2014
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How does population health succeed?

Obviously, this is not a question you can answer in a couple of sentences. It’s complex and there are numerous factors that attribute to the success of true population health, with multiple types of provider and/or payer organizations coordinating care for a segment of patients across a community. 

Naturally, we at Healthcare Informatics often focus on the informatics side of the equation. Indeed, without investment in health information technology (HIT), even the most well equipped healthcare organizations will fail when trying to undergo widespread care management.  As my editor-in-chief, Mark Hagland, wrote in his own blog, last month, this means “business intelligence/analytics, data warehousing, dashboarding/performance metrics,” and much more. This is impressive technology that can track regulatory measures, help maximize reimbursement, and more importantly, improve care outcomes, all through basic platforms and applications.

Yet as this year’s Healthcare Informatics Innovator Awards Program reveals, successful population health relies on more than just the implementation of advanced clinical information systems. Take, for instance, the Brooklyn Health Home. Led by a 706-bed academic medical center, the Brooklyn, NY-based Maimonides Medical Center, the health home is a consortium of approximately 50 medical, mental health, and social service organizations, payers, and a labor union, which have come together to create a “mental health home” for the seriously mentally ill (SMI) patient population in the area.

Maimonides/Brooklyn Health Home tied for second place in the Innovator Awards Program. I had the privilege of going to Maimonides, interviewing the team leaders of the health home project, and getting an idea of how they’re attempting to coordinate care for one of the healthcare industry’s notoriously toughest patient populations. After all, as the folks at Brooklyn Health Home told me, SMI patients die on average 25 years younger than the general population, usually have co-morbities, and don’t even always have a primary care physician.

One of the continuing elements of success within the Brooklyn Health Home are the care managers, the several hundred people who assess the needs of the SMI patients and connect them with services to address their medical, behavioral health, and social service needs. The care manager is described as the hub for all of the providers, monitoring and sharing electronic alerts of patient events and community wide patent clinical information. They’re linking and serving the providers on behalf of the patients.

As Madeline Rivera, R.N., chief of clinical integration at Brooklyn Health Home, said to me, “They are very much the boots on the ground.”

This role, the care manager, is a recurring theme when you look at successful population health management projects. Just look at our winning team in the Healthcare Informatics Innovator Awards Program: Catholic Medical Partners (CMP), a network of more than 900 independent primary care physicians, pediatricians and specialists, along with hospital partners at Catholic Health System in Buffalo and Mount St. Mary’s Hospital in Lewiston, N.Y.

CMP, profiled by my colleague Rajiv Leventhal, has implemented effective population health management, and it has done so by training and embedding more than 200 care coordinators, which in this case are nurses. The care coordinators at CMP, like the care managers at Brooklyn Health Home, are involved on the ground level work. In this case, they use electronic medical record (EMR) quality reports to target their interventions to their patients that need the most assistance.

I just spoke today with folks at Qsource, a Memphis-based nonprofit, healthcare quality improvement and information technology consultancy, which was tasked with generating widespread adoption of Direct in Tennessee. When they spoke of how they were able to get 4,000 providers signed on with Direct, the leaders of the project at Qsource and Tennessee Regional Extension Center (tnREC) gave a lot of credit to the “HIT Specialists.” They told me how these folks work in the community, educating providers, and getting them to sign up.

Sound somewhat familiar? 

When describing what makes a care manager, Rivera said the role can vary depending on the organization they’re serving. She meant within the Brooklyn Health Home, but might as well have been talking about the industry at large. Whether they’re nurses, community leaders, or social workers, are called care managers or care coordinators, they’re the ones educating, connecting, addressing issues, intervening, and making a difference.

Let’s give them some credit.

We’ll be honoring Brooklyn Health Home, CMP, and other Innovator Award winners at the 2014 HIMSS Conference in Orlando at an event on Monday Feb. 24 at 6:30. Click here to register.

Thoughts? Feel free to write something in the comments below or tweet me at @HCI_GPerna.