AMONG THE KEY TENETS of health care reform is increasing the focus of clinicians on the health care and cost of health care of populations of patients. It sounds simple. But population health management (PHM) is not the way health care traditionally has been provided. For decades, health care has been organized primarily around episodic interactions with individual patients. With PHM, however, care is organized around patients’ health needs regardless of whether they are seeking health care. The goal is better health for these patients – including more coordinated experiences and improved outcomes – as well as lower costs.
“It’s really about ensuring that we are building a system that enables us to proactively address the health needs of a population,” says Timothy Ferris, MD, vice president of the recently launched PHM effort at Partners HealthCare. Ferris also is an MGH primary care physician and medical director of the MGPO.
PHM requires some changes in how care is organized and delivered as well as how success is measured. It also requires identifying and engaging different patient populations. With this in mind, the first phase of the PHM program at Partners – part of the systemwide Partners Care Redesign – involves three main components:
- Patient-Centered Medical Home (PCMH): reorganizing primary care practices to provide team-based, patient-centered care for primary care patients, with heightened focus on prevention, chronic disease management and medically complex care. One example of this work is the development of a dashboard to help practices assess whether they have all the building blocks in place for a PCMH.
- High-Risk Care Management: supporting practices in providing robust care management – including better access, monitoring and care coordination – for complex, chronically ill patients who have a Partners or Partners Community Healthcare, Inc. primary care physician. The effort began at the MGH in 2006 and now is being spread to all Partners primary care practices. Approximately 20,000 patients have been identified as needing care management and 39 percent of them already have a care plan in place.
- Information Technology: developing the technology needed to improve workflow for clinicians and provide data and analysis for reporting and measuring success. For example, claims data warehouse has been used to collect and organize data, and processes now are in place to identify high-risk patients and patients with chronic diseases.
In the next phase, Ferris and his team will add specialty care and patient engagement programs to their charge. While the ultimate goal is managing the health of all patients who receive primary care through Partners, the PHM currently includes patients for whom Partners has risk-based, accountable-care contracts with payers.
“That’s approximately 500,000 patients, including those in our Pioneer ACO with Medicare, Partners employees, and patients covered by Blue Cross and Tufts contracts,” says Ferris. “We know that care is better using population health management tactics and having contracts that identify a target population and also include specific incentives to meet our goals helps us stay focused.”
Working with Ferris as medical directors for PMH are Sree Chaguturu, MD, an MGH physician, and Namita Seth Mohta, MD, a BWH physician.
Read more articles from the 9/7/12 Hotline issue.