Managing health at the community level can improve lives, cut costs, and spur economic development.
There’s a new kind of management worth keeping a close eye on: population health management.
Population health management looks at needs in order to address them and thus improve the lives of those affected. Just like an individual may have one, two or more diseases that can be evaluated and treated, populations can have patterns of problems that can be evaluated to minimize the effect of those problems.
Recent community measurement tools have divided health influences into four areas: health behaviors (30 percent), clinical care (20 percent), social and economic factors (40 percent), and physical environment (10 percent). Statistics show the Tri-County population has difficulty with: smoking, alcohol consumption, sedentary lifestyles and obesity (behavioral); prenatal care, preventable hospitalizations, cardiovascular and cancer prevention (clinical/medical); social factors such as violent crime, occupational fatalities and poverty; and other issues relating to the physical environment, such as walking paths or air quality.
Population health management evaluates these trends and develops strategies to reduce the impact at both the personal and population level. This is important, because reduction of illness often requires a broad-based effort. A community or employer can provide opportunities to increase physical fitness, but if the individual does not participate, it will not be effective. Conversely, someone may want to remain physically active, but their work or community environment discourages it.
It’s important to remember that community problems and individual illnesses are constantly changing. Some problems will get better, and others worse. It is essential to look at pattern changes to predict what will be needed and to be able to change quickly to address those needs.
The health of a population has significant importance to the economic potential of a region. Populations that are healthier, or are continually working towards better health, use fewer—and increasingly scarce—healthcare dollars and are more productive in other economic, community or cultural endeavors.
Moreover, the idea of population health management has significant economic development potential when trying to draw businesses to a community or retain current employers. Employers that pay attention to the health of their employees have a competitive advantage in talent recruitment, retention and productivity over their competitors. Three decades worth of data shows that the human resource cost in loss of productivity, personnel replacement, sick time, etc. is three times that of the medical cost.
How can healthcare providers help to improve the health of our community? By increasing our focus on care coordination and transition. Transition of care is when a patient is transferred from one provider or health setting to another. This requires good communication between the providers so that care is seamless.
For example, the care coordination in the prevention of cardiovascular disease may start with the primary care physician discussing physical activity and nutrition during school physicals, which is coordinated with diet and exercise programs for individuals, families or work environments. As an individual matures, health risk assessments point to individual needs that can be addressed through community, school or worksite initiatives.
Additionally, coordination of appropriate care can also relate to the intensity of care. This can be seen with diabetes. On one level, the treatment of diabetes involves health education regarding appropriate testing, education and treatment for diabetes. If the condition worsens, expertise may be required. If the diabetic has other conditions, a multidisciplinary team may be utilized. If the end of life is near, services such as supportive care, home care or hospice may be required.
OSF HealthCare’s approach involves having expertise to help individuals stay healthy and reduce disease from conception to death in a coordinated, comprehensive health system. This continuum of care has been acknowledged, with OSF being designated a Pioneer Accountable Care Organization (ACO), one of only 32 healthcare systems nationwide to earn that distinction.
Through population health management, it is our goal to improve the health and economic well-being of our community one patient at a time. iBi
Dr. Tim Vega is medical director of OSF Business and Community Health at OSF Saint Francis Medical Center.