During this April 28, 2016, Forum webinar, two population health providers, and a population health expert shared strategies for establishing and scaling a population health program by aligning the business and financial model.
Set a population health culture. Establishing a strong population health culture and incentive alignment among hospital staff, other providers, and community partners drives productivity and reduces costs of care, said Nilesh Chandra, managing consultant, healthcare, PA Consulting.
Design clinical pathways. Place equal emphasis on clinical and social determinants of health, said Rose Madden-Baer, senior vice president, population health management and clinical support services, Visiting Nurse Service of New York (VNSNY). Many individuals go back to the emergency department or are readmitted because they have no primary care physician, no assistance with medication adherence, or transportation to and from appointments.
Pay attention to the identification and stratification of patients. If participating in post-acute bundled payments, take special care to develop or purchase predictive analytics to identify the patients in your bundle by the final DRG that is determined after coding versus the working DRG provided to post-acute care providers, said Scott Vasey, senior vice president, strategy, VNSNY. Then, risk stratify the population to address the most significant care needs. Ongoing patient assessment throughout the episode ensures that patients receive the right amount of care regardless of the DRGs assigned throughout the care process, said Madden-Baer.