Population Health Management is about looking at key groups of people and devising ways to maximize their wellness.
In health care, it might focus on top users of health care services, or people with specific conditions, or people at high or rising risk for developing certain conditions. This is a very distinct departure from how health care traditionally addressed issues as they appeared, rather than preventing issues from developing at all or better managing existing conditions to maximize quality of life and avoid unnecessary problems.
Listen as Renee Smith, MD., Chief Medical Director, Aspirus Network Inc, explains the practice of Population Health Management at Aspirus Networks inc.
Population Health Management for Todays HealthCare Needs
Featured Speaker:
Learn more about Renee Smith, MD
Renee Smith, MD
Renee Smith, MD is the Chief Medical Director at Aspirus Network Inc.Learn more about Renee Smith, MD
Transcription:
Population Health Management for Todays HealthCare Needs
Melanie Cole (Host): Population Health Management is about looking at key groups of people and devising ways to maximize their wellness. This is a very distinct departure from how health care traditionally addressed certain issues. My guest today is Dr. Renee Smith. She's the interim executive director and the chief medical officer of the Aspirus Network, Inc. Welcome to the show, Dr. Smith. When we talk about Population Health Management, what are we really talking about?
Dr. Renee Smith (Guest): We're really taking a look at the patients that we serve and the communities that we serve and really taking a look at what do those communities, those individual communities, need for services and then how do we leverage what we're doing as a health system to support those needs.
Melanie: How is that even figured out? Is there data? Is there research? How do you figure out what it is that each specific community needs?
Dr. Smith: We really are working to be data-driven and we are really working on creating the sources of truth for that data and making sure that it is validated and does seem to meet the perception of what the community needs so that we can support what the perception is through the data that we find. So, we are using data, both in our electronic health record as well as claims data that our health plans are providing to us, to try to identify those community needs and then validate that data as we go out into the communities.
Melanie: It's certainly a big project and such an important one, when we look at certain communities and the lack of sidewalks or park districts or safe parks, and all of these have to do with health and wellness, even gym in recess in the schools, Dr. Smith. So, how do you tell patients and community, the people in the Aspirus community and beyond, to take this data and look at it as a preventive wellness initiative to help people get better before they get sick?
Dr. Smith: Well, really, it's about scoping. There are going to be levels to this project and we're going to start with the scope that we can directly affect and that we can directly have change and see change, and then, as we see that change and we have that what you could consider that win, then we can broaden it to those larger community needs around those preventative measures. But, really, it's starting with creating projects, analyzing the data around things that you can immediately change or have immediacy around and then building upon that momentum.
Melanie: For patients to get better health care, it's so important that they are their own best advocate. What do you think about that, about patients really getting involved in their health care, questioning things their doctors tell them, coming prepared to their appointments with questions and information?
Dr. Smith: I agree that is a huge component of where we need to go: making the patient feel that they play a role in that doctor's visit; that they are there as their own person, advocating for what they need, either questions answered or better understanding of the discussion that happened so that they can make good decisions around their health. These are things that programs that we have in place are working on to do which is empower the patient in their visit. What's beneficial to that is that provider/patient relationship only build and increases when that patient is getting their needs met in that visit. So, they come with questions, those questions get answered, they feel confident that they can ask those questions and be open and honest if they don't understand something that the doctor has said so that they are clear about what's going on and can make good decisions around their health needs.
Melanie: With the advent of electronic health records do you see that this is going to help to close care gaps and have cost savings for providers as well?
Dr. Smith: Electronic health records have been around for a while now and I think we are just now getting into the phase of the electronic health record where we hope to see that improvement. I think that in the early phases, we thought that we were going to see these a lot quicker than what has happened but as health systems have become more sophisticated in how we interact with our electronic health records, we will, hopefully, see that the promise that was made in the electronic health record will actually come to fruition in efficiencies and improved care, closing gaps in care and the like.
Melanie: As we're discussing population health management as a way to help preventive care and to keep costs low, where do you see the insurance companies on this, Dr. Smith? Purely in your opinion, do you think they're going to get on board with this?
Dr. Smith: I think from my perspective, having initially been only on the provider side and now in this position at the Aspirus Network interfacing with health plans a little bit more, they're trying to drive that cost efficiency and they're trying to drive that to get to a standard of care and get to best practice. What they haven't done well is partner with the providers to be successful and, so, it constantly feels like there's a battle going on, when really I think everybody's ultimate desire is really to provide that high quality, efficient care for our patients and for the health plan for the members. So, what we have seen, and what I think health plans are realizing, is that really building that relationship with health systems will help them become more successful so that it doesn't feel like a battle between the two groups when, in fact, they're working toward the same goal.
Melanie: Where do you see, again, in your opinion, some gaps that might need to be filled in the way of preventive medicine and wellness awareness in the community?
Dr. Smith: There are a couple of things. There's a lot of pressure driven down to the provider level. Pressure from health plans, pressure from the government in payment models and such. I think when that drives down to such a narrow point, you're going to get a bottleneck and it's going to be difficult to be successful. I think taking a look at what services and what models of care can be leveraged to accomplish goals around quality of care, gaps in care will be important as we move forward so that there is a broader success and all of those pressures don't just fall on one person shoulder or one group of people's shoulders. From sort of a community--still taking it from a patient level--one patient has gaps in care but from a community level, I think it really is around education. What can people do to maintain healthy lifestyles? What according to good evidence and best practice is highly recommended for screening? Why is it recommended? And, what can you prevent when you go and have your colon cancer screening done? How does that directly affect the community as an individual person community as well as the broader community in total?
Melanie: As care management is a critical component of this particular situation, then where do you see--and wrap this up for us, Dr. Smith--the revolving around improving patient self-management, maybe reducing admit rates. Kind of wrap it up with your best advice about population health management, and what you want the listeners to know about this initiative as a way to better the health of the community.
Dr. Smith: Sure. As it pertains to care management, I think what you're seeing with the development of care management programs is trying to get rid of that bottleneck that I talked about where all of the pressures are coming down to sort of one group of people shoulders but trying to leverage the skill sets that we have across our health system. We have two basically here at Aspirus Care Management programs we have the health resource team which is looking at a group of patients that see our health system in very complex ways. They see multiple providers. They might be going to have multiple procedures done. They could get help by having someone prepare them for the next visit. What questions do you have for that provider? Also as they exit the visit, what did the provider say? “Do you have any questions and follow up after you've seen the provider? What is the plan of care? How do you think you can execute on that plan of care?” so that patient can go from one visit to the next visit and feel empowered to ask the questions going into the visit and feel empowered leaving the visit that they can do what their provider has asked of them and know that they have someone there to support them through that. We also have a disease management component that's taking a look at very particular health issues. One of them is diabetes, one of them is high blood pressure, another one is congestive heart failure. So, patients who are dealing with that condition, what is preventing them to get to their optimal level of health? What barriers are there? Do they need a glucometer so that they can check their blood sugars if they have diabetes, which we know that if a patient with diabetes checks their blood sugars, they're more likely to be under control than someone who doesn't. What are the needs that a patient may have that we can help support them? And, again, what barriers may they have to preventing them from executing on what their provider has recommended, either blood sugar checks, or medication, taking their medications, can they afford the medication? Are they getting their medications in a timely manner? Is there something with the refills that aren't working? So, how can we make sure that we close those barriers or eliminate those barriers so patients can be successful as they deal with their health issues? Those are the two programs and really what’s that about is having added services, having added help, having a person that the patient can go to when their provider may or may not be available so that they know that there's someone walking with them through their individual issues to make them successful.
Melanie: Thank you so much, Dr. Smith, for being with us today. It's really such important information that the listeners really need to hear about Population Health Management and the Aspirus Community. You're listening to Aspirus Health Talk. For more information you can go to www.aspirus.org. That's www.aspirus.org. This is Melanie Cole. Thanks so much for listening.
Population Health Management for Todays HealthCare Needs
Melanie Cole (Host): Population Health Management is about looking at key groups of people and devising ways to maximize their wellness. This is a very distinct departure from how health care traditionally addressed certain issues. My guest today is Dr. Renee Smith. She's the interim executive director and the chief medical officer of the Aspirus Network, Inc. Welcome to the show, Dr. Smith. When we talk about Population Health Management, what are we really talking about?
Dr. Renee Smith (Guest): We're really taking a look at the patients that we serve and the communities that we serve and really taking a look at what do those communities, those individual communities, need for services and then how do we leverage what we're doing as a health system to support those needs.
Melanie: How is that even figured out? Is there data? Is there research? How do you figure out what it is that each specific community needs?
Dr. Smith: We really are working to be data-driven and we are really working on creating the sources of truth for that data and making sure that it is validated and does seem to meet the perception of what the community needs so that we can support what the perception is through the data that we find. So, we are using data, both in our electronic health record as well as claims data that our health plans are providing to us, to try to identify those community needs and then validate that data as we go out into the communities.
Melanie: It's certainly a big project and such an important one, when we look at certain communities and the lack of sidewalks or park districts or safe parks, and all of these have to do with health and wellness, even gym in recess in the schools, Dr. Smith. So, how do you tell patients and community, the people in the Aspirus community and beyond, to take this data and look at it as a preventive wellness initiative to help people get better before they get sick?
Dr. Smith: Well, really, it's about scoping. There are going to be levels to this project and we're going to start with the scope that we can directly affect and that we can directly have change and see change, and then, as we see that change and we have that what you could consider that win, then we can broaden it to those larger community needs around those preventative measures. But, really, it's starting with creating projects, analyzing the data around things that you can immediately change or have immediacy around and then building upon that momentum.
Melanie: For patients to get better health care, it's so important that they are their own best advocate. What do you think about that, about patients really getting involved in their health care, questioning things their doctors tell them, coming prepared to their appointments with questions and information?
Dr. Smith: I agree that is a huge component of where we need to go: making the patient feel that they play a role in that doctor's visit; that they are there as their own person, advocating for what they need, either questions answered or better understanding of the discussion that happened so that they can make good decisions around their health. These are things that programs that we have in place are working on to do which is empower the patient in their visit. What's beneficial to that is that provider/patient relationship only build and increases when that patient is getting their needs met in that visit. So, they come with questions, those questions get answered, they feel confident that they can ask those questions and be open and honest if they don't understand something that the doctor has said so that they are clear about what's going on and can make good decisions around their health needs.
Melanie: With the advent of electronic health records do you see that this is going to help to close care gaps and have cost savings for providers as well?
Dr. Smith: Electronic health records have been around for a while now and I think we are just now getting into the phase of the electronic health record where we hope to see that improvement. I think that in the early phases, we thought that we were going to see these a lot quicker than what has happened but as health systems have become more sophisticated in how we interact with our electronic health records, we will, hopefully, see that the promise that was made in the electronic health record will actually come to fruition in efficiencies and improved care, closing gaps in care and the like.
Melanie: As we're discussing population health management as a way to help preventive care and to keep costs low, where do you see the insurance companies on this, Dr. Smith? Purely in your opinion, do you think they're going to get on board with this?
Dr. Smith: I think from my perspective, having initially been only on the provider side and now in this position at the Aspirus Network interfacing with health plans a little bit more, they're trying to drive that cost efficiency and they're trying to drive that to get to a standard of care and get to best practice. What they haven't done well is partner with the providers to be successful and, so, it constantly feels like there's a battle going on, when really I think everybody's ultimate desire is really to provide that high quality, efficient care for our patients and for the health plan for the members. So, what we have seen, and what I think health plans are realizing, is that really building that relationship with health systems will help them become more successful so that it doesn't feel like a battle between the two groups when, in fact, they're working toward the same goal.
Melanie: Where do you see, again, in your opinion, some gaps that might need to be filled in the way of preventive medicine and wellness awareness in the community?
Dr. Smith: There are a couple of things. There's a lot of pressure driven down to the provider level. Pressure from health plans, pressure from the government in payment models and such. I think when that drives down to such a narrow point, you're going to get a bottleneck and it's going to be difficult to be successful. I think taking a look at what services and what models of care can be leveraged to accomplish goals around quality of care, gaps in care will be important as we move forward so that there is a broader success and all of those pressures don't just fall on one person shoulder or one group of people's shoulders. From sort of a community--still taking it from a patient level--one patient has gaps in care but from a community level, I think it really is around education. What can people do to maintain healthy lifestyles? What according to good evidence and best practice is highly recommended for screening? Why is it recommended? And, what can you prevent when you go and have your colon cancer screening done? How does that directly affect the community as an individual person community as well as the broader community in total?
Melanie: As care management is a critical component of this particular situation, then where do you see--and wrap this up for us, Dr. Smith--the revolving around improving patient self-management, maybe reducing admit rates. Kind of wrap it up with your best advice about population health management, and what you want the listeners to know about this initiative as a way to better the health of the community.
Dr. Smith: Sure. As it pertains to care management, I think what you're seeing with the development of care management programs is trying to get rid of that bottleneck that I talked about where all of the pressures are coming down to sort of one group of people shoulders but trying to leverage the skill sets that we have across our health system. We have two basically here at Aspirus Care Management programs we have the health resource team which is looking at a group of patients that see our health system in very complex ways. They see multiple providers. They might be going to have multiple procedures done. They could get help by having someone prepare them for the next visit. What questions do you have for that provider? Also as they exit the visit, what did the provider say? “Do you have any questions and follow up after you've seen the provider? What is the plan of care? How do you think you can execute on that plan of care?” so that patient can go from one visit to the next visit and feel empowered to ask the questions going into the visit and feel empowered leaving the visit that they can do what their provider has asked of them and know that they have someone there to support them through that. We also have a disease management component that's taking a look at very particular health issues. One of them is diabetes, one of them is high blood pressure, another one is congestive heart failure. So, patients who are dealing with that condition, what is preventing them to get to their optimal level of health? What barriers are there? Do they need a glucometer so that they can check their blood sugars if they have diabetes, which we know that if a patient with diabetes checks their blood sugars, they're more likely to be under control than someone who doesn't. What are the needs that a patient may have that we can help support them? And, again, what barriers may they have to preventing them from executing on what their provider has recommended, either blood sugar checks, or medication, taking their medications, can they afford the medication? Are they getting their medications in a timely manner? Is there something with the refills that aren't working? So, how can we make sure that we close those barriers or eliminate those barriers so patients can be successful as they deal with their health issues? Those are the two programs and really what’s that about is having added services, having added help, having a person that the patient can go to when their provider may or may not be available so that they know that there's someone walking with them through their individual issues to make them successful.
Melanie: Thank you so much, Dr. Smith, for being with us today. It's really such important information that the listeners really need to hear about Population Health Management and the Aspirus Community. You're listening to Aspirus Health Talk. For more information you can go to www.aspirus.org. That's www.aspirus.org. This is Melanie Cole. Thanks so much for listening.