Population Health Initiative
Strategic Health Solutions works with Payers and Plans to develop community specific support services integrating providers of all types
The Population Health Initiative (PHI) will address multiple chronic health issues in the affected footprint, particularly where conditions exhibit a high degree of comorbidity. The program relies on plan and provider data to identify the subpopulations diagnosed with the specific condition, and providing community education and social support services to increase condition literacy and enhance long term outcomes. As important, the PHI identifies that portion of the affected population which is currently most at-risk (cohort), which typically generates higher current claims and is at increased risk of acute and catastrophic occurrences. This combination can produce immediate current savings, while improving long term population health.
PHI will require
- Integration of services between participating FQHCs, hospitals and private physicians
- Integration of EHR platform, or bidirectional access to EHR platform between participating members
This strategy will utilize the following protocol:
- Identification of both the affected subpopulation and the high current risk population (cohort)
- Use of Patient Home Services to increase engagement and education of both subpopulations and cohort populations
- Enhanced measurement and monitoring of cohort population
- Formula based analytics to identify emerging crisis conditions as early as possible
- Integration of patient specific RX adherence
- Provider engagement through Patient Home infrastructure
- Measurement of ongoing metrics against goal and integration of quality measures
The Diabetic Intervention Program
The Diabetic Intervention Program is an initial step in the PHI strategy, and is designed to monitor individual and population metrics and implement appropriate quality measures. Data will be aggregated and monitored from a central platform and will include:
- Implementation of enhanced monitoring of glycemic control of cohort populations, via Bluetooth enablement, encryption to a mobile application and transmission to designated clinical provider
- Algorithmic analysis of uploaded, monitored results, coupled with RX adherence data
- Focused outreach for deteriorating patients
- Potential for telehealth video monitoring, as a supplement to on-site visits
Member screening uses available patient data feeds, including prior claims, health risk screenings, patient discharge data, direct referral from existing providers and RX utilization. Member stratification is based on severity of illness and comorbid conditions. The Diabetic Intervention Program will rely on population based, HEDIS Comprehensive Diabetes Care measures for outcome analysis. In addition to daily self blood glucose monitoring (which is then encrypted and transmitted to PHI providers), additional indicators such as lipid monitoring and control are tracked, as well as annual examination for visual indicators and kidney function. Ongoing monitoring ensures timely intervention in the event of a change in risk status. The frequency of member calls from Patient Home is determined by the severity of symptoms.
Diabetic supplies and Bluetooth-enabled glucometers are important aspects of the program. High-risk members (cohort) receive more frequent outreach from patient home infrastructure, including ongoing analysis of RX adherence. Further, metric indicated deterioration prompts immediate intervention.
A key goal of the program is to foster a collegial relationship between all affected providers (FQHC, hospital, private providers and value-based arrangements, such as existing ACOs).
- Patient Home outreach provides opportunity for preventive care and chronic condition improvement.
- Value based reimbursement models, leading to enhanced population health metrics
- Expanded monitoring of key metrics for specified conditions
