Provider-Led Population Health Management: Key Healthcare Strategies in the Cognitive Era, Second Edition draws connections among the new care-delivery models, the components of population health management, and the types of health IT that are required to support those components. The key concept that ties all of this together is that PHM requires a high degree of automation to reach everyone in a population, engage those patients in self-care, and maximize the chance that they will receive the proper preventive, chronic, and acute care. While this book is intended for healthcare executives and policy experts, anyone who is interested in health care can learn something from its exploration of the major issues that are stirring health care today. In the end, the momentous changes going on in health care will affect us all.
Autorentext
Richard Hodach is the author of Provider-Led Population Health Management: Key Strategies for Healthcare in the Cognitive Era, 2nd Edition, published by Wiley. Paul Grundy MD, MPH, FACOEM, FACPM, known as the "Godfather" of the Patient Centered Medical Home, member of the Institute of Medicine and recipient of the prestigious Barbara Starfield Primary Care Award.
Klappentext
Praise for Provider-Led Population Health Management
"This book addresses the most critical elements for providers as they transform themselves to provide population health management. Provider-Led Population Health Management is a must read for anyone interested in population health."
Donald W. Fisher, PhD, President and CEO, AMGA
"While there are many books on this subject, the clarity of someone well-trained and experienced provides insight into the real, dysfunctional working of the healthcare delivery system while providing useful guidance on working within the rapidly evolving dynamic it has become."
Don Fetterolf, MD, MBA, President, American College of Medical Quality
"This book is a real gem! Health care transformation to improve health, quality, and cost (the Triple Aim) requires new payment for value, new delivery systems founded on patient centered medical homes, and new information systems to support care of populations. The authors provide spot-on vision of how all three must work together, along with a detailed roadmap for success."
Michael K. Magill, MD, Professor and Chairman, Family and Preventive Medicine, Executive Medical Director, University of Utah Health Plans, University of Utah School of Medicine
"The authors bring a wealth of knowledge and experience in the field of population health management. Their keen insights into US healthcare transformation underscore the need for each healthcare system to have a well thought out and deliberate population health strategy."
Jeffrey Galles, DO, Chief Medical Officer, Utica Park Clinic
"The key message of this timely book is that healthcare teams must adopt automation to deliver on the promise of population health management. As my own organization has discovered, technology allows healthcare organizations to scale up quickly to prepare for value-based care. In this book are the practical strategies your organization can embrace today."
Ashok Rai, MD, President and Chief Executive Officer, Prevea Health
Inhalt
Acknowledgments vi
Foreword xiii
Introduction 1
Section 1: New Delivery Models 9
1 Population Health Management 11
What Is Population Health Management? 13
Key components 14
Obstacles to PHM 16
The Beginnings of Change 17
Examining the crucial role of automation 18
Managing the entire population 19
The Three Pillars of PHM 20
Conclusion 22
2 Accountable Care Organizations 25
The ACO Environment 27
Government support 28
ACO snapshots 29
Population health management 31
The role of information technology 32
Automation and analytic tools 33
Conclusion 35
3 Patient?-Centered Medical Homes 37
Initial Results Are Promising 38
Managing the Medical Neighborhood 40
PCMH Background 40
Medical home certification 41
Challenges and solutions 43
Building the medical neighborhood 44
How much will it cost? 45
Role of Information Technology 46
Automation tools 47
Conclusion 50
Section 2: How to Get There 51
4 Clinically Integrated Networks 53
Clinically Integrated Networks 54
Current definition 56
Basic requirements 56
Automation tools and CINs 58
Risk stratification 59
Patient outreach 60
Care management 60
Patient engagement 61
Post?-discharge care 63
Performance evaluation 63
The Need for Speed 64
Conclusion 64
5 Meaningful Use and Population Health Management 67
Meaningful Use Overview 68
Meaningful Use nuts?-and?-bolts 70
Upping the ante in Stages 2 and 3 71
PHM Components of Meaningful Use 71
Clinical decision support 72
Patient engagement 72
A leap forward for PHM 73
Health information exchange 74
MIPS and MACRA 76
Conclusion 77
6 Data Infrastructure 79
Data Sources 83
Administrative data 83
Clinical data 84
Claims data 84
Patient?-generated data 85
Provider attribution 86
Patient matching 87
Unstructured data 87
Data governance 88
Big Data's Role 88
Data lake approach 89
Data normalization 91
Analytics 91
Registries 92
Work lists 93
Predictive modeling 93
Risk stratification 94
Performance evaluation 95
Timely Response 95
Other Big Data Directions 96
Conclusion 97
7 Predictive Modeling 99
Predictive Modeling Basics 101
Turning Predictions into Action 103
Prescriptive analytics 104
Risk stratification 104
Directing resources 105
Making a difference 105
Automation tools 106
Clinical judgment and culture 107
Provider Attribution 108
Risk Adjustment 109
Financial Risk 110
Data Sources 112
Claims data 113
Clinical data 113
Patient?-reported data 114
Broadening the data palette 115
Conclusion 116
8 Automation Solutions and the ROI of Change 119
Transition to value?-based payments 121
The new return on investment 123
Automated Population Health Management 124
How Automation Produces ROI 126
Patient outreach 126
Analytics 127
Care management 128
Patient engagement 128
Transitions of care 129
How to Calculate ROI 130