Where the Action Is in Population Health: Upstream, System-Wide, and Community-Wide, Across the U.S.

Want to know where the population health phenomenon is going? In two words, “up” and “out.” Healthcare leaders are moving forward as never before to integrate new elements into their population health initiatives—and they’re showing results.

There are many terrific examples out there; I’ll reference just a few, from our publication’s recent reporting. One terrific example comes out of the work being done by the clinicians at Partners in Recovery, a 425-staff behavioral healthcare services agency that helps to manage the mental and physical care of residents of Maricopa County, the Arizona county that encompasses Phoenix. Partners in Recovery contracts with Mercy Care, a local health plan that cares for Medicaid, Medicare, and substance abuse care patients in Maricopa County.

The Partners in Recovery clinicians have created a high-risk registry that has identified high utilizers, and have leveraged a team-based care management model (involving a psychiatrist, nurse care manager, and others on the care team) to evaluate cases and determine the reasons for high ED utilization and inpatient admissions. As a result of their strategy and efforts, they have cut psychiatric admissions by nearly 50 percent and reduced the monthly cost of Emergency Department visits for its members from $2,265 to $875 in the last year.

Meanwhile, in the Portland, Oregon metropolitan area, a cadre of senior healthcare executives has been leading progress in the Children’s Health Alliance (CHA), compromised of about 120 practicing pediatricians, across 24 practice sites, who have created an independent practice association (IPA), in order to participate in value-based contracts with private and public payers in Oregon. Among the key forays the IPA has made have been into home-based services, including under capitated contracts, both with Oregon Medicaid, and with private payers in the state.

The CHA-affiliated clinicians have been focusing on specialty services utilization, having recognized that there is far less hospitalization in the pediatric population than in the adult population, and that developing a medical home approach has been the absolutely best strategy for managing utilization and keeping children healthier. As their colleagues at Partners in Recovery have been doing in Arizona, the CHA clinicians in Oregon have been digging deeply into the data, and in both cases, the clinician leaders agree that data analytics has been absolutely fundamental to their success so far in advancing population health management approaches with their patient populations.

Connecting with local communities has been an important element in many of these types of initiatives. During a July 11 meeting held by the National Quality Forum, Matthew Stiefel, senior director of the Center for Population Health at Kaiser Permanente, described for attendees a national initiative that Kaiser recently launched, called Thrive Local, in collaboration with an organization called UniteUs. The initiative has three aims, Stiefel explained to his audience: they are, to build resources directories of social service organizations; to build a network of resource providers; and to provide a platform that all the social service providers would be on, as well as the healthcare system, with bidirectional referrals and access to the electronic medical record. Research and evaluation remain very important to creating connections, including around the social determinants of health, Stiefel told attendees. And making those connections will provide the networks that can help improve the health status of vulnerable populations over the long term.

Nationwide, health plan leaders are already mapping out a connected-health future. As we reported on June 20, on that date, America’s Health Insurance Plans (AHIP), the Washington, D.C.-based national trade association representing the health insurance industry, announced during its annual AHIP Institute being held at the Music City Center convention center in downtown Nashville, that it was launching a new initiative aimed at addressing the social barriers to health.

The initiative, known as Project Link, according to AHIP officials, “will bring together health insurance providers from different markets and geographies to address an array of issues impacting all Americans, from housing to healthy eating to transportation. It will establish clear, collective strategies and goals for insurance providers, ensuring new programs addressing social determinants of health are scalable, sustainable, and measurable in improving health and affordability for everyone. Using Project Link as our foundation,” a press release published Thursday morning noted, “AHIP will develop research and policy agendas at both the state and federal level to improve the health, well-being, and financial stability for consumers, patients, and taxpayers.”

At the press briefing at which Project Link was announced, Ghita Worcester, senior vice president for public affairs and chief marketing officer, at the Minneapolis-based UCare health plan, a Medicaid plan, highlighted for the assembled press two groundbreaking programs that have seen successes in Minnesota. The first is the health plan’s Mobile Market, which involved the transformation of two used city buses into grocery stores on wheels, which provide access for poor people (whether UCare plan members or not) to fresh fruits and vegetables and other healthy foods, in concert with subsidies and purchase supports. The second is a program called Circles of Health and Well-being, a program targeted specifically at supporting Medicaid plan members in the southern Minnesota community of Faribault. Those members are Somali women who had no familiarity with the U.S. healthcare system, and who have had the opportunity to learn how the system works and how to appropriately access primary and preventive care, and who also have been taught about nutrition and healthy cooking. Both programs have proven to be highly successful, she noted, and will be expanded over time.

All of these initiatives have several things in common, including their broad vision of their communities and of the populations of patients they are caring for. The leaders of all these initiatives have also very robustly leveraged data and data analytics to conceptualize, analyze, and build their effective programs. And all have leveraged multidisciplinary approaches to extending their effectiveness as far and as fully as possible. The leaders of these initiatives have also been using the resources, connections, and networks that already exist in their worlds, and have been building on existing relationships and frameworks, whenever and wherever possible.

Finally, all these pioneers have framed their efforts as broadly as possible, and have thought holistically about populations and communities, incorporating the social determinants of health into their work, and strategizing towards ingenious solutions to the challenges that have faced them. And of course, all of these case studies also involve payer-provider collaboration at various levels and along a variety of dimensions.

In other words, we’re already moving into population health management 2.0—and the creativity can only be expected to continue to evolve forward going into the future.