Tag Archives: population health management

12 Things Healthcare Must Achieve Flash Video Series – Manage Social Determinants of Health

by Julius Heil, President and CEO, Intalere

During a recent presentation at Intermountain Healthcare, someone shared the phrase, “ZIP code is more important than genetic code,” when referencing what is now generally known as population health management. Healthcare providers must understand that they need a strategy to solve health problems before they show up in their emergency rooms, and that impacts made in the communities they service affect costs of healthcare delivery. Research has shown that initiatives focused on vulnerable populations in underserved communities significantly decrease ER visits.

Each year, through submissions to our Intalere Healthcare Achievement Awards program, we are seeing simple, yet effective community initiatives that are getting people more involved in their healthcare and general well-being. 

  • In partnership with a local non-profit food bank, Advance Community Health in Raleigh, N.C., launched a Mobile Food Market to provide increased access to healthy food, with an additional focus on measuring the health and behavioral outcomes of patients with diabetes or pre-diabetes having access to healthier food options.

An average of 33.5 people participated each week over the course of the 26-week program. More than 30,000 lbs. of healthy and fresh food was distributed in more than 1,740 grocery bags. The majority of participants completed the program feeling healthier, more confident in managing their diabetes, more familiar with healthy foods and better able to incorporate healthy foods into their daily lives.

  • Highlands Hospital in suburban Pittsburgh, Pa., developed and implemented the IM WELL Program (Integrative Medicine – Women Excelling Living Life). The program incorporates three domains of women’s health: nutritional, physical and mental. The program is open to all women ages 14 and older, and targets women who are uninsured or underinsured. In addition to core group classes, the program has a care coordinator who helps navigate women to appropriate community resources and services. The core group classes are taught by a licensed dietitian, a behavioral therapist, a certified integrative therapy nurse specialist, a certified diabetes educator and an exercise specialist.

The results of the program: 289 interactions with women, 780 phone calls, 400 health text messages answered, 391 follow-up appointments made for specialized health concerns and 50 interventions by the case manager. As a result of the program, 100% of the women met IM goals, 100% exercised at least three times per week, 58% were able to meet nutrition goals and 48% were able to meet water intake goals.

The mindset of caring only for individual patients in physicians’ waiting rooms must become a thing of the past. Hospitals are no longer concerned only with people in their beds. It’s not just about the sick in the era of pay for performance. Not only is population health the right thing to do, it’s the smart thing to do. The objective is to keep everyone healthy, and to do that requires healthcare providers to pay close attention to defined populations and coordinate their care.

Check out the latest video, Manage Social Determinants of Health, in our Flash Series and stay tuned in the coming weeks for more posts and videos about 12 Things Healthcare Must Achieve.

You can also download the executive briefing at Intalere.com.

Improving Margins Using Service Line Profitability Analysis

Joe Morrison, Intalere

By Joe Morrison, Director, Product Management, Intalere

Service lines are arguably the most utilized measure within healthcare organizations to quantify the financial health of any health system. While many organizations define their service lines slightly differently, their goal is the same – to improve the health and outcomes of patients while improving efficiencies and reducing the total costs within patient populations, all while remaining profitable.

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With the shift from fee-for-service to fee-for-value based care over the past several years, healthcare providers have endured significant margin compression on the services and service lines they offer to their communities. Outcome and episodic reimbursement momentum has impacted revenue streams and placed traditional ‘bread and butter’ service profitability in decline.

There are typically two main areas organizations focus on when looking at service line profitability to make up the gap in margin compression:

  • Increasing revenue streams – Examples may include investments into new services and focusing on outpatient markets.
  • Cost reduction initiatives – Which may include increased efficiencies around supply chain and reduction in physician preference items.

But, one cannot only think of service line optimization as simply the two areas of revenue and cost. Alignment of clinical outcomes and physician engagement are compulsory to effective and efficient service line management and improving margins.

Organizations that are positioning themselves for service line margin growth should be considering these four items:

  • Focus on population health management initiatives by expanding ambulatory services and physician alignment based upon patient population needs.
  • Understand, collect and analyze key metrics for service line margin improvement priorities and gather key stakeholders to understand and agree upon the metrics that will be monitored and benchmarked.
  • Analyze and map patient discharge data which can help an organization examine its primary service area and better understand the ever-changing market dynamics
  • Assess whether an investment in a service line, such as additional providers or marketing, will yield adequate revenue for a return on the investment.

Service line margin growth requires thoughtful use of related financial and clinical data paired with tools to help organizations understand where opportunities are hidden as well as teaming with physicians to reduce clinical variation and cost around unnecessary procedures and utilization of supplies.

Intalere’s OptiAnalytics Navigate delivers both organizational and physician performance to continually uncover opportunities for service line growth, identify areas for improvement, and evaluate market share and population trends.

The Annual Wellness Visit – The Foundation of Population Health Management

Shon Wettstein

By Shon Wettstein, Vice President, Business Development, Intalere

Physician groups that truly want to succeed in the new pay-for-performance era must transform themselves, focusing on a directed initiative to move to a population health management approach.

In doing so, they should explore the pros and cons of an aggressive health risk assessment (HRA) program, namely using the Medicare Annual Wellness Visit (AWV) as a tool for assessing the risk of an entire population of patients.

Because the AWV is a billable event, many physicians are unwilling to take on this tool because of the “cost” it adds to the expense side. However, evidence shows the “cost” is quickly outweighed by the “benefit” realized by reduced ER and hospital stays, less chronic disease costs, and lower medication and ancillary costs. The model of using the Medicare AWV as a vehicle of assessment can be a powerful tool in patient management and revenue generation.

One thing to keep in mind in this discussion – primary care doctors today are overwhelmed by time constraints. For this reason, a method of engaging patients proactively without using physician time or resources must be at the core of any assessment program. Merely putting a new template in your EHR won’t cut it, instead you need an affirmative program of patient engagement.

In terms of documentation, it is critical that the vehicle used to document the AWV correctly (to the absolute standards of the Centers for Medicare and Medicaid Services (CMS)) is also effective for the physician’s use. This document must be clear and succinct and must include a Risk Factor analysis, 5-year Plan and Personal Health Advice for the patient.

The other key piece of the puzzle is data, and the ability to access population data. If possible, the goal should be an integrated data analytics system that gives care coordination teams access to claims data, EHR data and prospective risk assessment data.

What can it mean to a typical practice? A practice with 1,000 Medicare patients can generally expect 70% of their patients for annual wellness visits. That can mean an average of an additional $200,000 in generated revenue.

Emphasizing proactive care to keep patients healthy, and improving communication and coordination among patients, doctors and other healthcare providers, is a foundational piece to the healthcare model of the future and the ability to provide sustainable, lower-cost, higher-quality care. The AWV can be the vehicle to drive that model.

To learn more, read our full article The Annual Wellness Visit Helps Maximize Revenue and Care Quality.

Intalere Member Best Practice Spotlight – Flagstaff Medical Center – New Patient Education Program Helps Patients Manage Their Health Conditions

The November Intalere Member Best Practice Spotlight shines on health education programs. This week we’ll look at Flagstaff Medical Center’s patient education efforts.


As Flagstaff Medical Center (FMC) builds a foundation for population health management, it is well understood that patient education is essential to getting patients well and teaching them effective methods for monitoring and managing their own health conditions in their home environment. FMC wanted to find a solution or tool that would complement and enhance the patient education efforts being carried out by the FMC nursing staff.


FMC worked with Engineered Care, Inc., to incorporate their Project RED: Re-engineered Discharge program at their facility to bring patient education to life and appeal to the learning needs – read, write, visual and auditory – of all patients. FMC and Engineered Care worked together to design and implement virtual health coaches/avatars for five specific diagnoses – Congestive Heart Failure (CHF), Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Active Myocardial Infarction (AMI) and post cath/stent placement – which make up a high percentage of admittances and readmissions. A comprehensive steering committee reviewed the educational content to be delivered by the virtual health coaches for core measure compliance and accuracy and to ensure that all remains in line with the overall FMC patient education process.


The first phase of this new patient education program involving virtual health coaches for CHF and Pneumonia was implemented in April 2013. Using Apple iPads, the virtual health coach teaching offered patients the ability to view the educational material as many times as they chose during their stay in the hospital, reinforcing understanding and supporting compliance with their health conditions post discharge. FMC is currently working on translating the virtual health coach education for CHF into the Navajo language, as this population makes up approximately 30 percent of FMC patients.

About Flagstaff Medical Center

A member of Northern Arizona Healthcare, Flagstaff Medical Center is a 267-bed inpatient hospital located two hours north of Phoenix at 7,000 feet above sea level. Founded in 1936, Flagstaff Medical Center is accredited by DNV.

Read more Intalere member success stories now!

Achieving Population Health Management

Photo - Todd Ebert 100x150

By Todd Ebert, President and CEO, Intalere

If you were to ask 10 different people to define Population Health Management (PHM), you might get 10 different answers. To put it simply, PHM means healthcare providers are responsible for caring for the health outcomes of defined groups (or populations) of patients. Physicians can no longer dwell in the mindset of caring only for individual patients in their waiting rooms, hospitals no longer with just people in their beds. It’s not just about the sick in this new era of reform.

The new models provide interventions to address patterns of morbidity, reduce costs and help people stay well. The focus is on minimizing chronic conditions and less episodic care. The objective is to keep everyone healthy, and to do that requires healthcare providers to pay close attention to defined populations and coordinate their care. Trends will include community coalitions, narrow networks taking patients through the continuum of care and evidence-based payment models.

At the recent Intalere Executive Forum, Intalere members and industry leaders gathered to discuss key elements of population health management and to review current successes by Intalere members Virginia Mason Medical Center, OSF Healthcare, Intermountain Healthcare and Samaritan Health Services.

All of these organizations have had success implementing programs that feature these important competencies:

  • –  Care automation
  • –  Care coordination
  • –  Reduction in readmissions
  • –  Cost and utilization measurement across the continuum of care
  • –  Improved patient compliance, no-show rates and engagement
  • –  Quality measure reporting
  • –  Patient stratification and interventions targeted to the right people and populations
  • –  Outreach and quality patient education
  • –  Connectivity to community-based organizations

All of this does take enormous time and money, but despite the costs, the incentives surrounding the inevitability of value-driven healthcare are too powerful to ignore. The future of healthcare will be what population health management is all about – the healthcare provider utilizing the right people and right resources, including technology, to provide better organized, more personalized and proactive care to all patients.

To learn more about key components and best practices in achieving PHM, download Intalere’s latest briefing, Keys to Achieving Population Health Management.

Understanding Population Health Management-Part 2

Anne M cropped

By Anne Mitchell (Anne.Mitchell@amerinet-gpo.com), Senior Director, Quality and Patient Safety, Intalere 

In last week’s post, we reviewed risk stratification and technology platforms. In this post, we’ll cover patient involvement and look at some best practices.

Patient Involvement

It is important to understand that patients also play a key role in helping to reduce the national trend of rising healthcare costs. Helping patients become educated healthcare consumers is a key element of population health management. This can be one of the more challenging aspects for healthcare providers as the high utilization populations with chronic and co-morbid conditions may have additional socioeconomic and psychological considerations such as limited education, substance abuse, lack of transportation and poverty that may hinder their involvement in self-advocacy.

Incentives such as gift cards, cash rewards and reductions in insurance premiums have been effective in drawing patients into a program, thus increasing the likelihood of the very essential active patient/family engagement and receptivity to coaching and general ownership of health maintenance practices.

The scientific best-practices and metrics designed for each unique population will continue to evolve as the body of shared information expands over time, always moving toward a safer, more efficient, patient-centered and equitable approach.

Looking for “Best Practice”

At the end of the day, supporting the wellness needs of patient populations will require healthcare leaders to implement large-scale improvements in processes and technology to ensure efficient coordination. Additionally, leaders need to have a strong commitment to aligning their physicians, payers and employees, as well as their communities. To accomplish this as efficiently as possible, leaders should look to organizations with integrated solutions to deal with population health management.

Best practice solutions should include:

  • Ability to identify at-risk patients, intervene, engage and evaluate (reduce 30-day readmission rates)
  • Own efficient, financially sound medical practices (ability to analyze downstream revenue to hospitals from medical practices)
  • Qualify physician practices for Patient-Centered Specialty Practice (gain additional practice revenue as a result)
  • Possess an integrated technology platform that connects disparate systems including long-term care and post-acute care  (allows for the connectivity and access to data to emphasize population health management)

All of this does take enormous time and money, but costs and efforts can be minimized by not “recreating the wheel” but using integrated solutions available on the market.  Despite the costs, the incentives surrounding the inevitability of value-driven healthcare are too powerful to ignore.

Contact Intalere now to find out how we can help with population health management.

Understanding Population Health Management-Part 1

Anne M cropped

By Anne Mitchell (Anne.Mitchell@amerinet-gpo.com), Senior Director, Quality and Patient Safety, Intalere 

Unsustainable costs, combined with widespread care coordination and quality gaps, have led to the inevitable large-scale efforts currently underway to redesign U.S. healthcare delivery systems and how care is funded. The traditional fee-for-service payment system, with its built-in incentives for more care, more testing and more expensive intervention has resulted in little provider alignment and accountability. Under recent federal legislative healthcare reform programs, most recently the Patient Protection and Affordable Care Act of 2010, all new levels of physician-provider-payer alignment will be required in order to reduce healthcare costs and ensure improved quality outcomes.

One of the relatively new approaches healthcare providers are taking to fulfill the federal requirements is Population Health Management (PHM). This is an industry term that means healthcare providers are responsible for caring for the health outcomes of defined groups (or populations) of patients. Physicians can no longer dwell in the mindset of caring only for individual patients in their waiting rooms. It’s not just about the sick in this new era of reform. The objective is to keep everyone healthy, but to do that requires healthcare providers to pay close attention to their entire population of patients and coordinate their care. And that’s what population health management is all about – the healthcare provider utilizing the right people and right resources, including technology, to provide better organized, more personalized and proactive care to all patients.

While there are many pieces that play a role in achieving population health management, three key highlights are:

  • Risk Stratification of the High-Utilization Population
  • Technology Platform for Care Coordination
  • Patient Involvement

Risk Stratification of the High-Utilization Population

Risk-stratified care management begins with a periodic and systematic Health Risk Assessment (HRA), using criteria from multiple sources to develop a personalized care plan. So as the industry shifts the focus from sickness to wellness, it will be essential to identify the chronically ill, high-utilization population and place them into meaningful categories for care management. Although the number of such diagnostically-related populations is endless, a few illustrative examples would include patients with Alzheimer’s, unstable diabetes, asthmatic children with recurring ED visits or hip replacement patients on Coumadin.

According to the Agency for Healthcare Research and Quality, five percent of patients are responsible for almost 50 percent of U.S. healthcare spending (2005). In order for healthcare provider networks to maximize their shared savings opportunities, it is essential to reduce the number of unnecessary in-patient admissions, emergency department visits, and interventional care and imaging services.

Technology Platform for Care Coordination

With the Primary Care Provider (PCP) as the nerve center of coordinating care management services for their entire panel of patients, a very robust IT system will be required in order to derive meaningful quality metrics and care guidelines. It will be crucial to have data management, analysis reports and performance dashboards to help providers enhance their care delivery, along with online portals with medical information for patients and clinicians to access.

Unlike other industries that are highly reliant upon the implementation of meaningful data analytics, healthcare continues to be in its infancy with regard to quality metrics. Although mandatory data elements have been reported for the last decade on a limited group of diagnosis-related group (DRG) categories, there remains a lack of scientific confirmation that improved patient outcomes are directly related to the metrics and subsequent patient care guidelines selected over past years. The appropriate weighting of each metric and the many DRGs with no related reporting requirements are just a few of the challenges of population health analytic science and business intelligence in healthcare.

Historically, healthcare payers have only had access to patient claims data while the provider relied solely upon the individual patient’s electronic medical record information. As we improve our ability to overlay population-level electronic medical records (EMR) and claims data through a robust technology platform, we will continue to see a more scientific understanding of the impact of our collective efforts around population health.

In next week’s post, we’ll look at the areas of patient involvement and best practices.

Contact Intalere now to find out how we can help your organization with population health management.