As ACA reforms continue to impact healthcare, population health management (PHM) is fast becoming the new buzzword for the management, integration and measurement of all interventions across the health continuum, from the healthiest populations to those with catastrophic illnesses. Rooted in the IHI's Triple Aim, PHM dives deep into health analytics to reduce risk and associated health spend and provide a strong foundation for accountable care in a value-based system.

Profiting from Population Health Management: Applying Analytics in Accountable Care provides both a primer in PHM, identifying the challenges and opportunities of a robust population health management program, and an advanced case study in the use of analytics in PHM.

In this 43-page resource, Patricia Curran, principal in Buck Consultants' National Clinical Practice, begins by offering an overview of population health management, underscoring the importance of data analysis and risk stratification and the tangible results both can deliver in terms of improved outcomes and cost savings.

Ms. Curran provides details on the following:

• The key factors in achieving results from population health management initiatives;
• Data collection and risk stratification strategies to optimize population health management results;
• Communication strategies to engage consumers in population health management; and
• Results from population health management programs.

This special report goes on to present a case study in PHM, in which care coordination is greatly enhanced by a data analytics framework. As part of its clinical transformation project, Bon Secours Health System has built a robust population health management platform, using custom builds in its EPIC electronic health record system to develop sophisticated reporting, patient registries and a predictive model to identify high-risk patients.

In the latest PHM resource from the Healthcare Intelligence Network, Robert Fortini, vice president, chief clinical officer at Bon Secours Health System, drills down on the tools and protocols tapped by the health system's embedded Nurse Navigators that are dramatically impacting readmissions, ER visits and other key utilization and cost metrics for this system.

Fortini covers the following:

• The types of registries Bon Secours uses to identify patients in need of care coordination;
• How Bon Secours has streamlined the time that it takes for nurses to document their patient interactions, including details on the training that the end users receive to efficiently use the system;
• The details on a predictive modeling tool that is embedded within the documentation system, including the formula used by the model to identify patients at-risk of readmission;
• The role of data analytics in a shared saving agreement between Bon Secours and Cigna; and
• Results from the program, including the impact on all-cause readmissions, patient and physician satisfaction and physician visit volume and productivity.

Profiting from Population Health Management: Applying Analytics in Accountable Care also answers more than 20 FAQs on the various aspects of PHM.

Table of Contents

• Population Health Management: Achieving Results in a Value-Based Healthcare System
  • Defining Population Health Management
  • Data Considerations for PHM Success
  • Managing Chronic Disease in a Specific Population
  • Using Incentives in PHM
  • Technology in PHM Infrastructure
  • Determining PHM's Value and ROI
• Improving Population Health Management Through Effective, Efficient Data Analytics
  • Reengineering the Patient-Centered Medical Home
  • Tools and Technologies for Nurse Navigators
  • Using Analytics to Determine Effectiveness of Interventions
  • EHR-Based High-Risk Registry
  • Evaluating Program Outcomes
  • Leveraging Processes and Workflows
• Q&A: Ask the Experts
  • Stratifying Patients Across the Continuum
  • Addressing Claims Data Lag
  • Strategies to Encourage HRA Completion
  • Cash-Based Versus Benefit-Based Incentives
  • Rewarding the Healthy
  • Benchmark Databases
  • Technology Adoption Among Employees
  • Engagement Strategies for PHM Programs
  • Medical Tourism in Plan Design
  • Collecting Data on Employee Perceptions
  • Slowing the Move from Healthy to At-Risk
  • Educating the Patient on PHM
  • Channels for PHM Communications
  • Social and Behavioral Techniques for Incentives Use
  • Moving from Incentives to Disincentives
  • Validating ROI from Population Health Management
  • Architecture for Delivery of Population Analytics
  • Defining Areas of Population Health Management
  • Engaging Providers in EHR Tools
  • Updating the SARG Database
  • Components of Medication Therapy Management
  • Disease Days for Chronic Illness
• Glossary
• For More Information
• About the Speakers