Home Care Heroes Blog

What is Population Health Management (PHM)?

Today's guest blog is submitted by Daniel Schwartz .  Daniel is a content strategist, digital marketing specialist and a health IT expert who provides perceptive, engaging and informative content on industry wide topics including EMR, practice management, interoperability, revenue cycle management, regulation, compliance and security

What is Population Health Management?

Population_health_management_AnkotaToday, individuals checking into a hospital or doctor’s office will find the process segregated by wealth just like any other business in the service industry. High costs and limited availability within healthcare—along with the various inconsistencies among care providers—has forced Americans to rethink the current model.

With Population Health Management (PHM), the goal is to keep the majority of the population healthy in hopes of avoiding high-priced alternatives, such as unexpected emergency visits, long hospitalizations, or invasive procedures like risky surgeries. In addition to lowering overall costs, PHM will prevent healthcare from becoming sick-care by focusing on the prevention of certain chronic ailments. Progressive ideas such as a PHM strategy require automation to be successful.

According to Well Centive, PHM is “the aggregation of patient data across multiple health information technology, resources, the analysis of that data into a single, actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes.” To summarize, it is important to understand that factors such as income, education, employment, culture, genetics, and environment cannot be recorded by a single entity. An act this massive will require many thinkers working towards the same goal.

Embracing and Defining Automation

Today, information-based technology can save time and money, much like creating an online search engine, linking together an ocean of information that was previously too tedious to sort. This medical automation also connects organizations directly to their community by filtering given clusters of demographics. By adapting an automatic approach to healthcare, providers reduce the need for continuous care management. This cuts out checks and balances while finding solutions to problems. Basically, certain routine tasks no longer need to be performed by specialists.


PHM aims to improve healthcare for larger populations by examining individual patients and recording that data. Current models involve a business intelligence tool that gathersstatistics to provide an all-inclusive medical portrait. This will help suppliers track and process clinical results while lowering expenses. The best models today use analytics involving scientific and monetary statistics to improve the efficiency of individual patient care. Similar to the way big businesses track massive amounts of data within social media, medical facilities will need to setup a system of analytical inventory to improve global healthcare.

Organizing Data Across Competitors

Despite that most organizations track the same types of information, few use the same software, and even fewer use the same methods of physician billing, electronic health care recording, or medical claims. To be successful, a universal program will need to look closely at clinicians and administrators to better identify gaps in clinical care, especially among chronic illnesses. Like-minded healthcare organizations that seek the PHM model must do so in a systematic manner for the greater good. Single entities must work with current community resources, healthcare associations, education facilities, and local groups aimed at improving overall health in their given neighborhoods. This massive undertaking to combine health care with social services will take a great deal of effort but the forward progression will be monumental.

Such a global idea will require significant changes in current thinking and practices. Rather than continuing the capitalistic tradition of the current healthcare model, providers will need to be rewarded for proficiency rather than admission alone. Healthcare providers will need to care for entire populations instead of individual, wealthy citizens. Hospitals must shift from high-priced admission revenues to save money for all. This will perhaps be the most difficult step, as these same providers will need to work towards a mutual goal of exchanging health information while still competing with one another for clientele.

When thinking in such massive terms, it is possible to become concerned that such idealistic views could tend to overlook one-on-one care management. On the contrary, understanding that care management will vary from one association to the next, each group will need to integrate self-management from patients, treatment supervision from doctors, and cost reduction from providers for the same cost of admission.

Taking Action

take_action-580x386For this transition to take effect, leaders in healthcare will need to take the reins, specifically within information technology and execution. With such an ambitious program, steps must be taken in an incremental method of small strides. Primary care practices will need to begin with call centers with automated features on a small scale in order to test and collect results. From a management point of view, patients will be classified within levels of their condition. Also, health insurers can use analytical algorithms to forecast which patients will be higher risks and thus more costly.

From a patient standpoint, the relationship with the physician will actually be stronger because of this automation. Those who lose touch with their providers will receive alerts, encouraging them to get in touch with their physicians to monitor their health. A strong doctor-patient relationship often encourages patients to change poor behaviors to achieve maximum results. An effective program can actually weave human interventions with robotic tools, such as automatic messages in call centers. Ongoing patient conversations can improve overall well being and avoid preventable deaths. This feedback benefits both sides of the relationship as it does with any business.

Delegating Special Skills

At the heart of this idealistic approach is primary care. Primary care physicians are currently in short supply and existing chronic care providers must work long days to fulfill the needs in their given areas. Physicians with special skillsets can perform much of this work, freeing up those with special skills to perform what they do best. Teams led by physicians and nurse practitioners can manage larger patient groups, addressing the needs of the many by delegating to dieticians, assistants, therapists, coaches, and others as they see fit.

The ultimate goal of Population Health Management is to improve the level of care while reducing expenses. In addition, PHM will improve continuing care by using IT solutions to track and manage care. A fully integrated search tool will help to close the gap by allowing administrators and physicians to have real-time access to records and thereby aid individual patient needs. Once laboratory, billing, electronic health record and prescription data are within the same search engine, providers can begin to easily pinpoint the massive needs and data gaps to better serve the population. As with all advances in healthcare management, PHM is a win-win for all parties involved: physicians, providers, and patients.

Editor's Note: At Ankota we believe strongly in the importance of population health as a way to provide improved health outcomes at lower cost to the broadest number of people (thus achieving the Triple Aim).  Further, we believe that home care will play a key role in achieving population health.  The medically fragile people in our population are generally elderly people with multiple chronic illnesses.  These are people who often need help with Activities of Daily Living (ADLs) that is provided by the home care industry.  We believe that the next extension will be to engage the health care industry in helping their clients to prevent avoidable hospitalizations.  Please consider downloading our free whitepaper, Why Care Transitions Is The Next Big Thing for the Home Care Industry and look for further announcements from Ankota regarding the role of home care in population health management.

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Ankota provides software to improve the delivery of care outside the hospital, focusing on efficiency and care coordination. Ankota's primary focus is on Care Transitions for Readmission avoidance and on management of Private Duty non-medical home care. To learn more, please visit www.ankota.com or contact us.




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