Population Health Management and Chronic Disease Patients

Growing healthcare costs, changing policy initiatives, and advancing technology have collided to produce a new concept that everyone in the healthcare industry is excited about: Population Health Management (PHM). The idea has been around for quite some time, but recently it’s been gaining traction as more organizations in the country strives to do something about the unaffordable state of America’s healthcare system. If you have a chronic disease, then you are probably all too familiar with the challenges of obtaining and managing adequate healthcare. But, do you understand Population Health and how it may affect you in the coming months and years? Find out below.

What is Population Health Management Really?

image: freedigitalphotos.net/samarttiw
image: freedigitalphotos.net/samarttiw

It is a buzz phrase that everybody’s concerned about, but what is it really? In general terms, PHM pertains to the health of a given population with a country, region or even a small community. It can refer to the health of the United States as a whole or that of a specific patient utilizing the services of a particular network of hospitals, clinics, and other health providers. Whichever specific population lies under the magnifying glass depends on who’s looking and what is being analyzed. Regardless, the practical nature of Population Health Management revolves around controlling the way healthcare is delivered in order to provide services that represent the best clinical practices, save money, and save lives.

Now, that you understand the huge expanse of space that PHM fits in–with its many surrounding networks of smaller regions or health systems–the next question that come forward usually is: How will it affect me? Simply put, the long-term trajectory aims to improve patient health outcomes while simultaneously increasing the affordability of services. That means that you might enjoy greater health at lower costs. However, if you are a patient with a chronic disease like diabetes, heart disease, or arthritis or one with genetic indicators for such a disease, then your role in the system is significant.

Managing Chronic Disease Populations

image: freedigitalphotos.net/watcharakun
image: freedigitalphotos.net/watcharakun

According to information from the Centers for Disease Control and Prevention, 75 percent of the nation’s healthcare dollars are spent on treatments for chronic diseases. Obviously, this is where any useful initiatives for Population Health must begin: within the population of chronic disease suffers.

The CDC listed heart disease and stroke as the first and third leading causes of death in Americans. Therefore, a major goal of PHM would be to find better methods of targeting and treating individuals at risk of these conditions in order to minimize mortality rates and lower overall health costs. Here’s a breakdown of just how Population Health Management might factor in for patients with heart disease:

  • Develop an index for patients with heart disease
  • Clearly define diagnostic criteria
  • Track patient outcomes based on type of treatment, type of condition and other factors
  • Look more closely at differing patient outcomes (i.e. those whose conditions worsen versus improve)
  • Identify patients who have not been evaluated recently or lack diagnostic tests
  • Identify patients with co-morbid chronic diseases such as diabetes or obesity
  • Utilize enterprise data warehouse (EDW) platform to flag patients with high-risk levels
  • Create mandatory screenings (i.e. blood pressure, cholesterol, etc.) for at-risk patients
  • Require a calcium score for individuals who fit risk profile of a certain age
  • Analyze the effectiveness of your interventions across other networks and other chronic diseases
image: freedigitalphotos.net/bejim
image: freedigitalphotos.net/bejim

Having access to data and being able to appropriately monitor and report on chronic disease patients and those at risk of these conditions is vital to managing the health of any population. Effective Population Health Management initiatives depend largely on identifying those individuals who are spending the most for healthcare, customizing a healthcare delivery system with their needs in mind, and working downwards to those who use the system less often.

As more information is gathered, analyzed and understood and as more technological advances are utilized for healthcare, both the definition and application of PHM will be refined or redefined. But this is granting us more time with loved ones and providing all of us with a better outlook on our health.