Population Management

1. Population Management • The following module is designed as a basic overview of population management for providers of healthcare, particularly those in a patient-centered medical home. • At the end of this module, the reader should be able to: • Define “population management” • Name 3 examples of successful population management strategies or programs • Outline 3 tools available to practices which may be used for population management of health conditions

2. What is Population Management? Factor 6: Care team members are trained in the concept of population management and proactively addressing needs of patients and families served by the practice. Population management is assessing and managing the health needs of a patient population such as defined groups of patients (e.g., patients with specific clinical conditions such as hypertension or diabetes, patients needing tests such as mammograms or immunizations). NCQA Patient-Centered Medical Home 2011 February 1, 2011

3. NCQA Certification Standards NCQA Patient-Centered Medical Home 2011 February 1, 2011

4. NCQA Certification Standards

5. NCQA Certification Standards

6. What Evidence do we have that this approach works? J Rural Health. 2003 Fall;19(4):506-10. • Promoting pneumococcal immunizations among rural Medicare beneficiaries using multiple strategies. Montana Department of Public Health and Human Services Am J Manag Care. 2012 Dec;18(12):821-9. • Population-based breast cancer screening in a primary care network.

7. Evidence for patient-centered medical home effectiveness targets population management

8. Insurance companies have been involved in some form of population management for decades

9. Employer Incentives Grow

11. Using the electronic health record to assess diabetes data

12. Tools for Population Management • Databases: registries, electronic medical record • Personnel: Nursing, PharmD, Physicians, MSW, Registration, Data experts, Statisticians, Researchers • Electronic Medical Record • Standing orders for preventive care • Nurse Case Management – targeting high risk patients with chronic disease

13. What resources are needed to begin a population management program? • Agenda • Goals • Demonstrated programs which are effective • Time/money/people

14. Questions • I have read each slide in this module and understood its content • True • False