Revolutionizing Population Health Approaches, Coordination in Health Care Setting

Nancy Myers, PhD, vice president at the American Hospital Association Center for Health Innovation, and James Dom Dera, MD, FAAFP, population health medical director at NewHealth Collaborative/Summa Health, recently spoke at Health Care Quality Congress 2019. Together they discussed care coordination in the health care setting and provided practical applications for both primary care and health systems.

Dr Myers began by saying that although health care has always been a team, a new team that is more well-coordinated is needed. She explained that population health is the health outcomes of a group that include the distribution of such outcomes within the group. Dr Myers emphasized that it is important to pay attention to the person who is directly in front of you and that there are different patterns of needs, as well as outcomes.

Drs Myers and Dom Dera explained the pathway to
population health can be divided into different categories. “We’ve divided it into four portfolios,” Dr Myers said.

• Portfolio 1: Physical and/or mental health
• Portfolio 2: Social and/or spiritual well-being
• Portfolio 3: Community health well-being
• Portfolio 4: Communities of solutions

Drs Myer and Dom Dera explained that primary care is associated with higher quality and lower cost care.

“Primary care is associated with improved patient experience of care,” Dr Dom Dera said, adding that everyone has a vested interest in care coordination. All of the interest is geared toward triple aim, high quality, lower cost, and improved patient satisfaction.

“One of the most important things primary care practices can do is risk stratify,” Dr Dom Dera said. According to the session, higher risk patients require more care coordination. He said it is important to identify higher risk patients and wrap resources around them. “Care coordination is critical for higher risk patients.”

Dr Dom Dera explained that it is important to use risk scores to guide therapy. “The goal of risk stratification is to manage patients based on their clinical need, using their risk score…In general, the risk score is proportional to resource utilization.” He noted that higher risk level requires more resources.

Dr Dom Dera then asked a handful of what-if questions, including:

• What if patients could see be seen when they needed to be seen?
• What if primary care providers clearly asked the specialists what’s needed of the consult?
• What if specialists answered the question and clearly spelled out next steps?
• What if everyone knows what’s going on because all relevant information is shared?

Based on these questions, Dr Dom Dera highlighted the importance of care coordination agreements. He suggested having a contract between two parties. Further, he said it is important to spell out expectations between primary care providers and specialists who are part of the agreement.

“By themselves, care coordination contracts don’t do anything to foster a culture of coordination,” he said. “Successful care coordination requires a culture change.”

According to Dr Dom Dera, process redesign, patient engagement, staff education, and partnering all make up the culture. He briefly highlighted behavioral health integration models and social determinants of health. 

He told the audience that, “We can all agree these are important factors.”

“So how are all of these tied together—social determinants of health, behavioral health integration, and care coordination?”

He explained that the more complex patient case, the more likely that all of these models will overlap.

Drs Myers and Dom Dera concluded that shared foundations are important. Health plans can utilize actionable information for care coordination, use data analytics to identify and track at risk patients, integrate care coordination support, and use support of community partnerships and referral processes. —Julie Gould