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Provider-Led Population Health Management: Key Strategies for Healthcare in the Cognitive Era, 2nd Edition

Provider-Led Population Health Management: Key Strategies for Healthcare in the Cognitive Era, 2nd Edition

Richard Hodach, Paul Grundy, Anil Jain, Michael Weiner, Karen Ezekiel Handmaker (Editor)

ISBN: 978-1-119-27725-5

Sep 2016

264 pages

Select type: E-Book

$16.99

Description

Provider-Led Population Health Management: Key Healthcare Strategies in the Cognitive Era, Second Edition draws connections among the new care-delivery models, the components of population health management, and the types of health IT that are required to support those components. The key concept that ties all of this together is that PHM requires a high degree of automation to reach everyone in a population, engage those patients in self-care, and maximize the chance that they will receive the proper preventive, chronic, and acute care.

While this book is intended for healthcare executives and policy experts, anyone who is interested in health care can learn something from its exploration of the major issues that are stirring health care today. In the end, the momentous changes going on in health care will affect us all.

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Acknowledgments  vi

Foreword  xiii

Introduction  1

Section 1: New Delivery Models  9

1 Population Health Management 11

What Is Population Health Management? 13

Key components 14

Obstacles to PHM 16

The Beginnings of Change 17

Examining the crucial role of automation 18

Managing the entire population 19

The Three Pillars of PHM 20

Conclusion 22

2 Accountable Care Organizations 25

The ACO Environment 27

Government support 28

ACO snapshots 29

Population health management 31

The role of information technology 32

Automation and analytic tools 33

Conclusion 35

3 Patient?-Centered Medical Homes 37

Initial Results Are Promising 38

Managing the Medical Neighborhood 40

PCMH Background 40

Medical home certification 41

Challenges and solutions 43

Building the medical neighborhood 44

How much will it cost? 45

Role of Information Technology 46

Automation tools 47

Conclusion 50

Section 2: How to Get There  51

4 Clinically Integrated Networks 53

Clinically Integrated Networks 54

Current definition 56

Basic requirements 56

Automation tools and CINs 58

Risk stratification 59

Patient outreach 60

Care management 60

Patient engagement 61

Post?-discharge care 63

Performance evaluation 63

The Need for Speed 64

Conclusion 64

5 Meaningful Use and Population Health Management 67

Meaningful Use Overview 68

Meaningful Use nuts?-and?-bolts 70

Upping the ante in Stages 2 and 3 71

PHM Components of Meaningful Use 71

Clinical decision support 72

Patient engagement 72

A leap forward for PHM 73

Health information exchange 74

MIPS and MACRA 76

Conclusion 77

6 Data Infrastructure 79

Data Sources 83

Administrative data 83

Clinical data 84

Claims data 84

Patient?-generated data 85

Provider attribution 86

Patient matching 87

Unstructured data 87

Data governance 88

Big Data’s Role 88

Data lake approach 89

Data normalization 91

Analytics 91

Registries 92

Work lists 93

Predictive modeling 93

Risk stratification 94

Performance evaluation 95

Timely Response 95

Other Big Data Directions 96

Conclusion 97

7 Predictive Modeling 99

Predictive Modeling Basics 101

Turning Predictions into Action 103

Prescriptive analytics 104

Risk stratification 104

Directing resources 105

Making a difference 105

Automation tools 106

Clinical judgment and culture 107

Provider Attribution 108

Risk Adjustment 109

Financial Risk 110

Data Sources 112

Claims data 113

Clinical data 113

Patient?-reported data 114

Broadening the data palette 115

Conclusion 116

8 Automation Solutions and the ROI of Change 119

Transition to value?-based payments 121

The new return on investment 123

Automated Population Health Management 124

How Automation Produces ROI 126

Patient outreach 126

Analytics 127

Care management 128

Patient engagement 128

Transitions of care 129

How to Calculate ROI 130

Patient outreach: Additional visit revenues 131

Pay-for-performance: Maximizing incentives 131

Risk contracts: Lowering overall costs 132

The bottom line 132

Conclusion 133

Section 3: Implementing Change  135

9 Care Coordination 137

Defining Care Coordination 139

The Physician Group Practice Demonstration 140

The Patient?-Centered Medical Home 141

Technology solutions 142

NCQA criteria 143

Technology Use in Care Coordination 145

Key building blocks 146

Continuum of care 148

Conclusion 149

10 Lean Care Management 151

A Lean Foundation in Health Care 154

High?-Performing Practices 157

Performing at top of license 158

Care?-coordination approaches 159

Lean Care Management 160

Automation in Lean Processes 162

Basic automation tools 163

Top?-of?-license approach 166

Downstream value 166

Conclusion 167

11 Patient Engagement 169

The Physician?-Patient Relationship 171

How to Engage Patients 172

Activation models 173

Obstacles to patient engagement 174

Care Management 175

Patient outreach 175

Risk stratification 176

Patient education 177

Telemedicine 178

Mobile health apps 179

Personal health records 180

Social media 181

Conclusion 182

12 Automated Post?-Discharge Care 185

New Government Incentives 186

Gaps in Care Transitions 188

Poor educational techniques 188

Poor handovers 189

Best Practices 190

IHI’s patient?-centered approach 190

Coleman Care Transitions Intervention 191

Naylor Transitional Care Model 191

Automation 192

Assessing patient risk 193

Patient education and engagement 194

Connecting providers to each other 194

Conclusion 195

13 Social and Behavioral Determinants of Health 197

SDH Impact on Health 200

Approaches to SDH 201

Model 1: Targeting health behaviors 201

Model 2: Referral to community services 203

Model 3: Targeted social support within a healthcare framework 204

Model 4: Patient?-centered medical homes 205

Model 5: Holistic care management 206

Behavioral Health 208

Advantages of integration 209

Solving the SDH Puzzle 210

Team?-based approach 212

Harnessing technology 213

Other data sources 214

Conclusion 216

14 Cognitive Computing: The Future of Population Health Management 219

Cognitive Computing 101 223

IBM Watson arrives 224

Natural Language Processing 225

Unstructured EHR data 226

Medical literature 228

Data Types 228

Genomic data 229

Imaging data 230

Monitoring data 230

Non?-healthcare data 232

Population Health Management 232

Predictive modeling 233

Patient engagement 234

Care coordination 235

Workflow integration 235

Conclusion 236

Conclusion  239

End Notes 241