Population Management

• The following module is designed as a basic overview of population management for providers of healthcare, particularly those in a patient-centered medical home.

• At the end of this module, the reader should be able to:– Define “population management”– Name 3 examples of successful population management

strategies or programs– Outline 3 tools available to practices which may be used for

population management of health conditions

What is Population Management?

Factor 6: Care team members are trained in the concept of population management and proactively addressing needs of patients and families served by the practice.Population management is assessing and managing the health needs of a patient population such as defined groups of patients (e.g., patients with specific clinical conditions such as hypertension or diabetes, patients needing tests such as mammograms or immunizations).

NCQA Patient-Centered Medical Home 2011 February 1, 2011

NCQA Certification Standards

NCQA Patient-Centered Medical Home 2011 February 1, 2011

NCQA Certification Standards

NCQA Certification Standards

What Evidence do we have that this approach works?

J Rural Health. 2003 Fall;19(4):506-10.• Promoting pneumococcal immunizations

among rural Medicare beneficiaries using multiple strategies. Montana Department of Public Health and Human Services

Am J Manag Care. 2012 Dec;18(12):821-9.• Population-based breast cancer screening in a

primary care network.

Evidence for patient-centered medical home effectiveness targets population management

Insurance companies have been involved in some form of population management for decades

Employer Incentives Grow

Companies Increase Wellness Incentive DollarsMost U.S. companies planned to increase the dollar value of the incentives they offer employees to participate in health improvement programs in 2012, according to an employer survey by Fidelity Investments and the not-for-profit National Business Group on Health fielded Nov. 1-Dec. 30, 2011, among U.S. companies ranging in size from 1,000 to 100,000 employees. Among the top findings from the survey:• Almost three out of four companies (73 percent) used incentives to engage employees in health improvement programs.• The average incentive value was $460. That figure has increased steadily from an average of $430 in 2010 and $260 in 2009. • Employers used different types of incentives, including cash, gift cards and contributions to health savings accounts. • Program costs. Incentives aside, employers spent on average $169 per employee on health improvement programs in 2011, up from $154 in 2010 and $108 in 2009. • Most popular offerings. Smoking cessation and employee assistance programs (EAPs) were the most prevalent lifestyle management offerings in the workplace.

Using the electronic health record to assess diabetes data

Time-frame: 7/1/12 - 6/30/13 Column1Data for UIM Current PCPs only (as of 7/23/13) - does not include missing PCPs8179

# < 8 % < 8 # ≥ 8 % ≥ 8 Total visitsGreen 757 63% 446 37% 1203Blue 719 63% 424 37% 1143Pink 1005 69% 445 31% 1450Yellow 682 60% 446 40% 1128Pod 1 616 77% 179 23% 795Pod 2 444 67% 222 33% 666Pod 3 675 72% 258 28% 933Pod 4 624 72% 237 28% 861Totals 5522 68% 2657 32%

Tools for Population Management

• Databases: registries, electronic medical record• Personnel: Nursing, PharmD, Physicians, MSW,

Registration, Data experts, Statisticians, Researchers

• Electronic Medical Record• Standing orders for preventive care• Nurse Case Management – targeting high risk

patients with chronic disease

What resources are needed to begin a population management program?

• Agenda• Goals• Demonstrated programs which are effective• Time/money/people

Questions

• I have read each slide in this module and understood its content– True– False