Paths to Population Health: Is there strong supporting infrastructure in place?
These new ways of working require a supporting infrastructure so clinicians feel confident they are able to perform the new tasks and roles required of them. This means ensuring the organization can support them through:
- Population management – healthcare professionals must have the ability to identify the target population for a given service and stratify it for the different risks that individuals and groups have from those conditions. This requires the ability to link patient data including prescribing, primary care and hospital encounters.
- Bringing all the data together – either virtually or in a single repository, is an important step. As well as health information, data about the patient’s social context greatly improves the predictive power of the models.
- Reaching out to patients – designing services that help patients manage their own health more efficiently. This could include expert patient programs, condition specific technology such as apps, proactive visits by staff and better care planning. See the case studies in this report or KPMG International’s previous report Creating new value with patients, carers and communities for how this works in practice.
- Utilization management – in the context of coordinated care, ensuring that the location and type of care is appropriate for the needs of the patient. Often this forms the foundations of strategies to shift care into patients’ homes.
- Clinical decision support – coordination is difficult if clinicians in one part of the coordinated system are uncertain about how other parts of the system manage care. Standardized, evidence-based tools and processes as well as transparency between organizations, will give professionals the confidence to transfer care to other providers. Geisinger’s ProvenCare system, see page 10, is one example of this in practice.
- Reporting and performance management – the move away from isolated episodes of care is a particular challenge for many performance management systems, but ways must be found to assess an individual’s contribution in the context of the wider pathway and in terms of patient outcomes.
A key challenge will be that the skills to develop and run some of this new infrastructure are scarce. However, not all of these functions need to be provided in-house. Outsourcing, joint ventures with other providers and partnerships with technology companies will play an important role in releasing economies of scale and moving to more sophisticated forms of outcome based finance, HR and data management.
The article is an excerpt from our thought leadership: Paths to population health Achieving coordinated and accountable care