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The Role of Population Health in Managing High Risk Populations

The Role of Population Health in Managing High Risk Populations | Miguel McInnis | Scoop.it
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Miguel McInnis's curator insight, December 12, 2014 10:17 AM

  by Miguel McInnis, MPH

 

Population health management (PHM) has made significant inroads due to the emergence of various integrated delivery systems including patient-centered medical homes, hospital-based readmission prevention programs and accountable care organizations. Population health is broadly defined as the health outcomes of specific groups of people, including the distribution of these outcomes within the group. These groups can be large geographic populations or smaller groups of people such as specific ethnic groups, disabled people, inmates in a prison and so on. PHM also involves providing a wide spectrum of healthcare services that are directed at behavioral changes and encouraging healthy lifestyles to obtain optimal outcomes.

 

PMH is increasingly being used to target high risk populations. The PHM approach exhibits a significant overlap with existing care management programs, but offers additional tactics to improve both clinical and financial outcomes of the target populations. Evolving PHM strategies and more complex care management interventions are being deployed and integrated to help case managers that are directly engaged in health activities to understand the changing landscape.

 

The PHM Model

 

The main aim of PHM is to improve health outcomes of groups of people by improving the quality of care, providing better access to care and increasing preventive care. PHM has the potential to improve the health care system while at the same time making significant cost reductions. The PHM model is based on utilizing teams of care givers such as care managers, attending physicians and a host of other providers and the patients’ family members. One of the hallmarks of the PHM model is its comprehensive nature and flexibility.

 

PHM has become more significant due to the shifting reimbursement strategies, including performance-based compensation. More hospital resources are being allocated to outpatient care as opposed to being mainly channeled to inpatients care as was previously the case. PHM requires stakeholders to leverage advances in technology including identifying relevant metrics that fit the needs of the target group, providing culturally competent support services and using various forms of communication.

Population Health Management systems are made up of several platforms:

 

Population Health Intelligence Platforms

 

Population health intelligence platforms are used to provide plan administrators and care teams with secure web-based access to comprehensive financial and clinical information. These platforms access clinical data and other patient data from multiple sources. They also give users easy access to predictive analysis, population risk stratification, hospital admission data, disease registries and referral data. The platform seamlessly connects to data warehouses that store third-party information.

 

 

Medical Management Systems

 

Medical management systems combine people and information to create highly personalized and effective services that are used to manage acute care management, chronic care management, wellness management and utilization management. Accurate integrated data is used by PHM systems to identify at-risk patients, track results, analyze care and support wellness management. This helps patients experience fewer hospital and emergency visits.

 

 Risk Stratification

 

PHM risk stratification tools are used to identify different population needs across all levels of risk and design the appropriate interventions to address the needs of the population across the entire continuum. These tools use demographics, care patterns, medical conditions and resource utilization to stratify patients into five main categories namely episode of care patients; high risk patients; chronically ill patients; healthy patients but with conditions and healthy patients. This information is used by medical providers in healthcare management and decision making.

 

Population Engagement

Population engagement services help in motivating patients to become partners in their own healthcare. The aim at building supportive and long-lasting relationships and use third-party data to identify patient needs and foster active relationships between PCPs or other healthcare providers and patients.

 

Predictive Analytics

 

Predictive analytics tools are used to model medical conditions within population to identify high risk patients long before they require expensive care and is a useful tool in budget planning.

 

Leveraging Healthcare Technology Advances

Healthcare technology has grown immensely in its ability to target high risk populations. One  the most dramatic uses of technology to reach patients with poor access to technology involves the implementation of telehealth. Telehealth is a broad term used to refer to advances in use of healthcare technology in practitioner training, deliverance of services and continuing medical education.

 

McInnis & Associates is a healthcare management consulting firm that specializes in delivering exceptional value by designing solutions that deliver consumer value as well as increasing revenue and market share. Additionally, we are healthcare experts in serving the needs of underserved populations. If you need any help in designing and implementing a PHM model to help you target high risk populations, please call us and we will be glad to share our insights with you.

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Improved communication needed to reduce hospital visits, study says - ModernHealthcare.com

Improved communication needed to reduce hospital visits, study says - ModernHealthcare.com | Miguel McInnis | Scoop.it
Improved communication needed to reduce hospital visits, study says
ModernHealthcare.com
It really speaks to the importance of quality reporting,” said William Prentice, CEO of the Ambulatory Surgery Center Association.
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Six Skills Middle Managers Need

Six Skills Middle Managers Need | Miguel McInnis | Scoop.it
Joseph L. Bower, professor at Harvard Business School, describes how to be an effective general manager.
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How Successful People Reach Their Goals

How Successful People Reach Their Goals | Miguel McInnis | Scoop.it
Heidi Grant Halvorson, author of Nine Things Successful People Do Differently, shares proven tactics for setting and achieving your goals — no matter how distant they seem.
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The Dangerous Myth of Reinvention

The Dangerous Myth of Reinvention | Miguel McInnis | Scoop.it
It's time to rethink the fantasy of 50- and 60-somethings confronting uncharted career territory.
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Health-care economics

Health-care economics | Miguel McInnis | Scoop.it

Some Obamacare ‘flaws’ are really prime examples of free markets at work.

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Find Success Your Own Way

Find Success Your Own Way | Miguel McInnis | Scoop.it
Robert Steven Kaplan, author of What You're Really Meant to Do, explains how to reach your unique potential.
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Passion is critical to success. You do not develop passion as a result of your success.

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Unwinding Inequality

Miguel McInnis's insight:

When we allow inequality in business, it undermines capitalism and capital markets.

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Start-Up Leaders Recall Choice to Cash In or Stay Independent

Start-Up Leaders Recall Choice to Cash In or Stay Independent | Miguel McInnis | Scoop.it
Nine start-up founders recounted the moment they had to decide whether to sell or stay independent — when the money was on the table and the future was unpredictable.
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Study may explain why brain 'perceives limited information'

Study may explain why brain 'perceives limited information' | Miguel McInnis | Scoop.it

Scientists have long studied why our brains choose to process only a small amount of information we come across in everyday life. Some information reaches our consciousness, while other information - although absorbed - takes a back seat. But a new study may shed light on why this happens.

 

Through using a common visual illusion, called "binocular rivalry," researchers from the Centre for Integrative Neuroscience (CIN) at the University of Tübingen in Germany were able to pinpoint a significant difference between conscious and unconscious motion that is represented in the brain.

 

The researchers say that our eyes usually see the same image. The process of binocular rivalry occurs when each eye is shown a completely different image.

 

Through this process, the researchers explain, our brains are unable to decide which image to process, with our perception moving between the two images every few seconds. This means the images are "rivals" for our attention, taking turns to enter our consciousness.

 

The researchers found that the magnetic pulses that stimulated the motion area had no effect on the length of time that the moving image was perceived. However, they found that participants perceived the still image for longer.

 

However, they add that once participants did become aware of the moving image, magnetic pulses had no effect.

The researchers say:

 

"This result suggests a substantial qualitative difference between the conscious and unconscious representation of motion.

 

Transcranial magnetic stimulation can easily weaken a suppressed representation and thus delay the time when it becomes dominant again. However, once motion becomes conscious, it is harder to disrupt."

 

More: http://www.medicalnewstoday.com/articles/267870.php


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Danielle Gillespie's curator insight, September 9, 2014 8:30 PM

Interesting article about the brain, using qualitative research @ashali89

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Understanding The Relationship Between HIE and Population Health

Understanding The Relationship Between HIE and Population Health | Miguel McInnis | Scoop.it

Electronic Health Record (EHR) technology has been a huge contributor to the increased collection of data in a consistent and quality manner. Unfortunately, EHRs effectively silo their data within the walls of individual practices and health systems – which is a major barrier to communication, care coordination and collaboration, and efficient health care delivery. HIEswere created to address this barrier by allowing HIT systems and healthcare providers to exchange information in order to deliver high-quality, cost-effective care.

 

All Health Information Exchange is Local

 

How HIE is accomplished is affected by numerous variables, including community type (urban vs. rural), geographic regions, number of hospitals, community interest, HIE infrastructure maturity, etc. Two types of HIEs exist today: public and private.

 

Public HIEs: Commonly referred to as “community” HIEs. Typically managed, open to, and supported by the communities with which they serve.

 

Private HIEs: Primarily governed by a single healthcare system or integrated delivery network (IDN).


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Miguel McInnis's curator insight, April 27, 2013 7:43 AM

Great infographic highlighting the relationship betweein HIE and Population Health

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The Things You Do Often Create The Things You Believe

The Things You Do Often Create The Things You Believe | Miguel McInnis | Scoop.it
The process of creating the right culture in a startup has always been mysterious to me. Each company's culture evolves in its own way.
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Why I Put My Company on a Year-Long Sabbatical

Why I Put My Company on a Year-Long Sabbatical | Miguel McInnis | Scoop.it
The answer is simple: So we could come back even better.
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Something to consider.

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CEOs Should Get Out of the Saddle Before They’re Pushed Out

CEOs Should Get Out of the Saddle Before They’re Pushed Out | Miguel McInnis | Scoop.it
Smart CEOs leave after about five years, no matter how well the company is doing.
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The Most Important Question You Can Ask Yourself Today

The Most Important Question You Can Ask Yourself Today | Miguel McInnis | Scoop.it
If I ask you, "What do you want out of life?" and you say something like, "I want to be happy and have a great family and a job I like," it's so ubiquitous that it doesn't even mean anything. What's more interesting to me is what pain do you want?
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Julian Treasure: 5 ways to listen better

http://www.ted.com In our louder and louder world, says sound expert Julian Treasure, "We are losing our listening." In this short, fascinating talk, Treasur...
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The Costs of Racial Color Blindness

Michael I. Norton presents a game similar to "Guess Who?"—play along and for a glimpse into his recent research.
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