Population health refers to health outcomes of a group of individuals, often those living in a certain community or geographic area. For office-based physicians, the group would include all patients on that practice’s panel. Integrating population health techniques into practice-based care can benefit individual patients as well as the practice’s bottom line. Consider the following strategies to help integrate population health methods into patient care.
Analyze your patient population. This can help you identify the most common diagnoses in your practice and decide where to focus resources. Some practices with large numbers of patients with similar problems develop or connect patients to education programs that address those issues, such as an evidence-based diabetes prevention program at a local YMCA.
Call no-shows. Following up when someone doesn’t keep an appointment or cancels without rescheduling can reveal obstacles to care. One practice found that arranging transportation for a patient was well worth the expense compared with facing another missed appointment.
Flag patients with 2 or more chronic diseases for more intensive management. Medicare offers reimbursement for the management of patients with at least 2 chronic diseases, including phone calls to schedule patients for needed care or email reminders. Activating this option for your patients with long-term conditions may increase your bottom line and improve your patients’ health.
Maintain communication. Notify patients when their medications are recalled or discontinued or when new treatments or clinical trials are available for their condition. In addition to ensuring continuity of care, this also builds trust and patient satisfaction—both of which are associated with better health outcomes.
Most of these techniques rely on data from electronic health records (EHRs) and practice management programs, but some practices can also use registry or other population health overlays in conjunction with EHR systems. Others rely on simple paper-based records to keep “watchlists” of patients with poorly controlled conditions or those who need to return for follow-up visits.
Whatever methods you use, make sure to develop practice policies to ensure consistent notation and hold training sessions for staff and clinicians. Importantly, not all EHR systems are created equal (even if they are certified) when it comes to pulling reports and other necessary data. Above all, check the accuracy of the data before jumping to conclusions if something looks wrong.