An Agile Plan for Population Health

The Foundation

Achieving success in “Population Health” requires developing systems to meet medical care and service needs effectively and efficiently at the individual patient level. Population Health equals healthcare and services appropriately delivered to individual patients for all patients in the plan. This means successful Population Health programs must have the capacity to deliver customized care and services for each individual.  

The Process

Individual, patient centered, health care begins with an annual wellness visit that results in an annual plan of care. The plan of care will vary by patient based on their level of illness as well as their level of independence, their current support structure, and their social/economic status (home, transportation etc.). The role of the primary care provider, in collaboration with a population health team, is to assess the patient’s condition across these factors and develop the plan of care. The plan of care should identify the medical care to be provided over the next three to twelve months, depending on the patient’s health status. The plan of care should also identify the additional services (ex. transportation, home remodeling for the handicapped etc.) the patient will need to enhance the success of medical services. In every case a set of expectations should be established for the patient to have a successful outcome. 

The ultimate goal is to move each patient from sickness and dependence to health and independence.  Considering this goal, the Plan of Care must also identify expected outcomes. At the medical level, these outcomes will include a reduction in the frequency and magnitude of acute care episodes as well as improvements in vital health indicators. Nonmedical outcomes should demonstrate steps toward the goal of independence.

To achieve a successful outcome, there must be recurring monitoring to make sure the patient is staying on course. The monitoring system must also have a means to notify providers of the need for intervention when the patient begins to stray from the plan of care. The intensity of monitoring will vary depending on each patient’s medical condition as well as his/her social and economic status. Some patients may only need a call once every six months while others may require daily monitoring. The plan of care should identify the monitoring requirement based on each patient’s medical condition and status along with the other factors listed above.

When to Begin

Rather than waiting to build an infrastructure that will address all the needs of all the patients, we can begin one patient at a time. Start with the patient who has the greatest need, develop the annual plan of care, then obtain the care/services that patient needs. Next, assign resources to monitor the patient’s status in accordance with the plan and establish an exception reporting system that ensures responsive intervention when needed. Once these steps have been completed move to the next patient with the same process. As you develop plans and meet needs for each patient you will be pulling from resources already identified for prior patients, so the process should become more efficient. When available resources are exhausted you must take steps to expand capacity either by making more efficient use of current resources or finding additional resources to meet the need.

 How to Pay for these Services

This model is best applied with an at risk (capitated) patient population. The application of activity-based costing techniques to each patient’s plan of care will identify the total costs involved in executing the care plan.  These costs should be compared to the expected medical costs for the patient if there was no care plan intervention. The patient’s medical condition and history of health system utilization should be the primary factors used to project future costs in the absence of intervention. Typically, the up-front costs invested in care plan execution will be far less than the costs for periods of high acuity (ER visits, admissions, etc.) experienced by the patient in the absence of a proactive care plan. Armed with positive results, demonstrating reductions in healthcare costs, the population health care team should request up-front funding from the at-risk health system. A discerning health system will recognize the benefit of reducing total costs by investing in more intense front-end patient management. This model becomes scalable to the extent the front-end investments continue to be less than the medical costs generated in the absence of an intervention.

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