January 23 2019 | 0 Comments | 88 reads Average Rating: 3

7 Steps Toward More Comprehensive Population Health Management

by David Hom in Population Health

In order for healthcare organizations to succeed with their population health programs, they should strive to identify, prioritize and close open care gaps. However, this is easier said than done when they are faced with a number or challenges that limit them from a complete view of the patient or member.

Most providers today are relying on clinical data only. Most health plans are relying on claims data only. Each are working with the data they have access to, but this isn’t enough if the goal is total population health management.

Here are seven steps that you can take to gain a more comprehensive view and proactively close care gaps and, in the process, create population health programs that get results:

1. Combine claims with clinical data to create a more timely and accurate view of the patient’s current health.

2. Use aggregated data to build a longitudinal view of each patient’s current health, risk, and cost profile.

3. Create risk scores at multiple levels that help your healthcare organization prioritize where your limited care management resources are assigned based on where you will deliver the best clinical and financial results.

4. Add in outside data such as social determinants of health, psychographic, and other types of data that offer insights into who patients are, how they live, and what motivates them.

5. Assign an impactability score to each patient that shows which care gaps to close first and what the value of doing so is.

6. Place the scores in a dashboard view.

7. Judiciously match resources to care gaps.

After taking this final step, you might determine that getting a morbidly obese patient with chronic hypertension to participate actively in a weight management program could pay significant dividends whereas other interventions with other patients might not have much of an impact.

This blog is based on Closing the Knowledge Gaps in Care Gap Management, an article that was published in Healthcare Analytics News.

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David Hom
Chief Evangelist

Dave is an internationally-recognized expert in the field of consumer engagement through programs such as Value Based Benefits and Employee Wellness.

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