Removing Barriers in Oder to Achieve Your Population Health Goals

Nurse Leader Insider, February 22, 2018

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By Tabassum Salam, MD, FACP, CHCQM

In our world of healthcare, in this era of rising costs and ongoing pressures on reimbursement, the transition to population health is already here (Kotzabauer, Weeks, 2015). The movement might assume different names, such as value-based payments or accountable care or bundled payments, but this shift can no longer be ignored. In either voluntary or mandated programs, many healthcare providers and systems have ventured away from episodic healthcare to providing longitudinal care to cohorts of patients. Caring for large groups of patients, while simultaneously optimizing clinical outcomes and controlling healthcare costs, gives us the opportunity to organize healthcare in novel ways. In order to do so successfully, we need to be aware of potential barriers to our success, and identify workable solutions. Here are some starting points to consider.

Pick realistic strategies and timelines

In order to optimize healthcare value, your population health team will aim to increase the quality of care, or reduce the cost of care, or opt to achieve both simultaneously. Your energetic population health team will generate hundreds of creative means to achieve these goals. This can be both a great strength and a drawback. It is essential to be strategic and selective about the interventions that you put in place, so as to raise the efficiency and effectiveness of your population health programming. It is also crucial to have realistic timelines for your population health initiatives.  Not all interventions will bear fruit within a few months, and your population health team needs to allow them to mature.

Stratify the population in order to target interventions

Once your population health team has selected its strategies, the next practice step is to stratify the population being served, in order to target interventions to those patients most likely to benefit from them.  For example, with a timeframe of two years in mind, you may choose to outreach to a sub-group of patients who has only one chronic disease and work with them to stabilize their condition and prevent progression of the disease. Or if your team is looking for short-term wins within a year, they may choose to target a sub-group of patients who frequently require hospital-based care and provide resources to help these patients avoid recurrent admissions.

Utilize Information Technology to mine actionable data and inform your initiatives

Information technology has much to offer to population health management, through the intersection of electronic health records, huge data warehouses, analytics and machine learning. Most healthcare providers and population health teams are now lucky to have access to multiple sources of data, for example, clinical data from electronic health records, registries, or health information exchanges, or financial data from claims. Avoid being mesmerized by ‘big data’, instead, remember to make big data work for your initiative.  Establish your clinical goal and intervention framework first, and then harness analytic tools to answer your population-focused questions and find the opportunities for improvement.

Be persistent in engaging patients in self-management

Population health initiatives are most successful when empowered patients are at the core. We have moved past the era of simply educating patients in good health practices. It is now essential to activate patients to contribute actively to managing their health and healthcare-related choices (Hibbard, Greene, 2013). In order to do so, it is vital to be pragmatic about the social, financial and psychological factors that influence patient behavior. Hence a multi-disciplinary population health team will likely be most effective – it should not only comprise physicians and other healthcare providers, but also include social workers, health coaches and peer educators. Motivating patients to this shift towards self-management takes time and persistence, for the knowledge, skills and attitudes needed have traditionally not been emphasized.

The transition to population health is both exciting and daunting to some. It does require realignment of priorities and goals, culture change among patients and healthcare providers, and grappling with and vetting the potential benefits of information technology. With a step-wise approach apparent barriers to this transition can systematically be shifted into great opportunities for success.

Tabassum Salam, MD, FACP, CHCQM is the Senior Physician Advisor, Department of Quality, Safety and Population Health, Christiana Care Health System – 2017 CHCQM Diplomate Achievement Award Winner


Hibbard, J.  H. H.  & Greene, J. What the evidence shows about patient activation: Better health outcomes and care experiences; Fewer data on costs. Health Affairs, February 2013, 32, no. 2, pp. 207 – 214.

Kotzbauer, G. & Weeks, W. W. Developing the organizational competencies needed in value-based payment systems. Healthcare Financial Management, July 2015, pp. 76-77.

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