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The American Journal of Accountable Care September 2018
Improving Population Health Through Multistakeholder Partnerships
Nicole Sweeney, BA; Sarika Aggarwal, MD, MHCM; Peter Aran, MD; Deb Dahl, MBA; Joseph Manganelli, PharmD, MPA; Steven Peskin, MD, MBA; Emily Allinder Scott, MHA; David Parker, PhD; Joseph Conoshenti, RPh, MBA; and Anupam B. Jena, MD, PhD
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A Model for Delivering Population Health Across the Care Continuum
Sanjula Jain, PhD; Adam S. Wilk, PhD; Kenneth E. Thorpe, PhD; and S. Patrick Hammond, MHA
“Lean” Improvement in the Quality of Patient Care in the Hospital Admissions Process
Patricia Bonachela Solás, BSc; José Bernabéu-Wittel, MD; M. Nieves Romero Rodríguez, MD; Antonio Castro Torres, MD; and Diego Núñez García, MD
Patient Complexity Characteristics in the Hospital Setting
Baptiste Crelier, MMed; Sven Streit, MD; and Jacques D. Donzé, MD, MSc
Trends in Healthcare Payments: Focus on Consumer Experience as the New Normal
Chris Seib, BS
Effectiveness of Enhanced Primary Care on Preventive Health Services
Sarah L. Goff, MD; Lorna Murphy, MA, MPH; Alexander Knee, MS; Haley Guhn-Knight, BS; Audrey Guhn, MD; and Peter K. Lindenauer, MD, MSc

A Model for Delivering Population Health Across the Care Continuum

Sanjula Jain, PhD; Adam S. Wilk, PhD; Kenneth E. Thorpe, PhD; and S. Patrick Hammond, MHA
The Population Health Care Delivery Model presents delivery systems with a framework for developing, piloting, and implementing population health programs across the continuum of care.
ABSTRACT

Objectives: While most payers have been slow to embrace models that would incentivize value-based care delivery, providers have a unique opportunity to take the lead in this endeavor. We examine best practices to develop a Population Health Care Delivery Model (PHCDM) to guide delivery systems as they design and pilot population health programs across the continuum of patient care and to facilitate their coordination with individual clinicians.

Study Design: Systematic review.

Methods: A systematic review of observational studies and health system case studies was conducted. We examined the effectiveness of population health–oriented programs and specific quality improvement initiatives in improving the health outcomes of patient populations across the continuum of care. Our assessment was primarily focused on the structural and design features of successful programs.

Results: We find that population health improvement is a result of (1) prevention and well care and (2) disease management initiatives that are both patient-centered and population-oriented in structure. We identified differences in care delivery objectives as the severity of disease increases across the patient care continuum. The corresponding PHCDM presents a framework for providers to systematically pilot and evaluate population healthcare programs.

Conclusions: The delivery system–clinician partnership is essential to coordinating evidence-based practices across the care continuum and, as a result, strengthening relationships with payers to further incentivize population healthcare delivery.

Am J Accountable Care. 2018;9(3):16-22
There is growing recognition that paying for the delivery of high-quality, efficient healthcare is necessary to improve population health. Such value-based payment systems place a growing amount of revenue at risk for clinicians, although most continue to practice in care models developed under fee-for-service incentives. This asymmetry has raised concerns among clinicians about these systems’ implications for patient care, reporting requirements, and payment levels.1 The concurrent shift toward increased employment of physicians in large delivery systems2 may reflect, in part, clinicians looking to their delivery systems to help navigate the complexity of value-based payment systems. 

At the core of these emerging payment models is the expectation that care providers must be accountable for the health outcomes of entire patient populations across the continuum of care. Delivery systems must be reoriented to achieve these aims. At times, this work will be inexact, challenging, and even conflicted when other health system stakeholders’ responses to the system’s new population health objectives are asynchronous or askew with the providers’ efforts. Alternately, the pace of advancement toward population health management will accelerate if the delivery system’s efforts are supported by robust payment systems that are developed in collaboration with payers and reward incremental progress toward value-based care objectives. Although most payers have been slow to fully embrace alternative payment models (APMs) that would strongly incentivize value-based care delivery and promote population health, providers have a unique opportunity to take the lead in this endeavor.

Delivery systems are uniquely positioned both to help clinicians adapt to new payment regimes and to lead the way in developing and evaluating new models of population healthcare delivery. Delivery systems can play key roles in innovation, infrastructure investment, measurement, and contracting, as well as provide strategic direction and leadership in this enterprise. However, a delivery system’s investments and reorientation toward system-level functions3 could lead to diminished emphasis on patient-centeredness in care at the individual level. To ensure that patient care is not compromised, the delivery system must engage and collaborate with all stakeholders, particularly clinicians, and reflect their priorities in their new population healthcare delivery models.4-7 This system–clinician partnership is essential to coordinating evidence-based practices across all silos of the care continuum and strengthening relationships with payers to incentivize population healthcare delivery.

Balancing Population-Centered Care and Patient-Centered Care

It is a long-established ethic of the individual clinician to focus intently and autonomously on the individual patient in the exam room and deliver optimal patient-centered care in accordance with the patient’s preferences and needs.8 Likewise, each delivery system’s approach to delivering high-value population health must be unique to the needs of the population it serves. Where these approaches are successful, it will be in no small part because individual clinicians are effective in their new roles as executors of the delivery system’s population health initiatives and resources. However, individual clinicians may view these tasks as in conflict with their traditional patient-centered care delivery approaches, occupying time and resources that should be devoted to the patient’s immediate needs in the exam room. Hence, clinicians depend on the delivery system to recognize how they are being pulled in these 2 different directions and set reasonable expectations as they grow accustomed to their dual roles. Balancing these expectations requires the system to be diligent in monitoring clinician deviations from evidence-based recommended care practices and distinguish systematically between appropriate variation (eg, due to high-acuity complex patient needs) and avoidable variation in practice.

Ideally, clinicians’ care delivery models and the delivery system’s strategy are well-coordinated to ensure that the patient population receives efficient population-centered care while individual patients continue to receive effective patient-centered care. In this paper, we present a new framework, the Population Health Care Delivery Model (PHCDM) (Figure), to guide delivery systems as they design, pilot, and implement population health programs across the continuum of patient care and to facilitate their coordination with individual clinicians. The care continuum, as patients experience it, is useful for framing the objectives of a population health–oriented system in a way that recognizes the individual clinician’s autonomy and patient-centered perspective. In the following sections, we explain the aspirational goals of the PHCDM, rather than specific recommended tasks, recognizing that the effective delivery of population health requires nuanced approaches tailored to the needs of different patient populations. We also delineate new terms of collaboration between the delivery system and the front-line clinician within this framework.


 
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