If you had to create a bumper sticker to sum up the concept of population health management, “It takes a village to care for a village” would get the point across.

Because communities and patient populations are simultaneously diverse and interconnected, providers must take an integrated, interdisciplinary approach to care delivery to make the population health model work.

In break-out sessions on data analytics, clinical redesign, and strategic partnerships, they discussed the challenges, benefits, and tools needed to shift from fee-for-service care focused on acute care to a value-based model that stretches across care delivery sites and into the community.

Fine-Tuning the Data

When it comes to narrowing down the needs of a patient population, healthcare providers can find data analytics to be extremely valuable. “We’ve had a fair amount of success using analytics to help with readmission reduction work,” says Andrew L. Masica, MD, MSCI, vice president and chief clinical effectiveness officer at Baylor Scott and White in Dallas.

“The tool in use classifies patients as having certain risk levels,” he says. “Those who are categorized as high-risk for readmission during their hospital stay get a comprehensive care coordination intervention and, in many patients greater than age 65, home visits from a nurse practitioner to help with the transitional period following discharge. Medium- and lower-risk patients receive lesser degrees of intervention, for example, phone follow-up, tailored to meet any specific identified needs.”

“That’s been a very efficient way to manage resources,” he says. “The nurse practitioner model for transitional care has been shown to be effective but can be resource-intensive from a hospital operational standpoint.”

While there is value in numbers, however, Masica explains that the benefits of analytics can only be had if the numbers are strong. “Too much information, particularly if delivered in the wrong fashion, isn’t helpful and can sometimes be harmful,” he says.

In fact, attendees ranked inadequate or incomplete longitudinal clinical data as the biggest challenge facing their organizations in performing data analytics in a pre-event survey by HealthLeaders Media.

Putting a Population in Perspective

Another consideration regarding data analytics is that there’s more to a population’s health than just percentages. There are nuances to care outcomes that can be found hiding within subjective data.

“When you talk about population health and you limit the conversation to data analytics — that’s just the tiniest sliver of that solution,” says Alan Pitt, MD, professor of neuroradiology at Dignity Healthcare in Phoenix. “I think there’s a big role for the objective EHR data, but also [for] the subjective data … that would be more relevant to something of a solution.”

Traditionally, healthcare has relied on objective data collected about the patient through a claim or an EHR report rather than through self-reported data from the patient report, Pitt says. “Subjective data is patient-reported data, ‘How do you feel about that surgery you had 3 weeks ago? Are you back to walking? What is your pain level?”

This type of data could be key to getting a broader, more accurate picture of how the patient is doing and what interventions he or she may need. “The piece missing is the subjective data that goes beyond the hospital, beyond the clinic, [and] all the way to the home, to figure out value and outcome.” Pitt says.

When providers connect with patients at the home and community levels, they also have the opportunity to identify risk factors that prevent patients from achieving their optimal level of health. Barriers to care play a large role in determining whether a patient becomes a high-risk individual.

“If you drill down, you see that a lot of [risk factors] are social barriers to access,” says Frank C. Astor, MD, MBA, FACS, chief medical officer NCH Healthcare System. “There’s transportation, there’s domestic violence. There’s a whole bunch of other issues that are difficult to deal with but you’re going to have to deal with no matter what.”

The New Frontier

The same could be said about population health management.

It’s something healthcare systems will have to deal with no matter what. Healthcare is not going to stay static any longer, and the shift from receiving care in acute, hospital settings has begun. Clinical transformation has begun and new care models are beginning to take shape. According to the HealthLeaders Media October 2014 Population Health Intelligence Report, healthcare reform is focusing on value, and population health management is one model to provide fiscally responsible, effective care.

The new model will move beyond the walls of the hospital, linking all points of care and all healthcare disciplines.