What Is Population Health Management (PHM)?

Population Health Management (PHM), an integral part of the healthcare system in the U.S, tend to govern the process of care to a community of people having similar healthcare needs. According to the founder of the Yale Department of Public Health, C.-E.A. Winslow, "PHM is the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals."

PHM is acting as a unified platform of analytics for improving the insights of patients, care managers, and care providers towards population health. Care providers can find outpatients who need primary healthcare interventions. This helps in laying a proactive foundation for improved preventive care and better disease management.

With PHM, patients are now getting involved in different patient meeting platforms to fulfill their care goals. They participate actively or passively via remote monitoring means. As per the U.S. Department of Health and Human Services, over 91% of hospitals and approximately 75% of the U.S. eligible professionals use Electronic Health Records (EHR), which is sanctioned for Stage 1 usage.

PHM itself encompasses proactive implementation of strategies and interventions to specify the cohorts of people groups across the gamut of healthcare delivery for sustaining or improving the health at the lowest possible cost. Marking a shift from acute care due to electronic data availability, PHM is now focusing on shared accountability provisions to increase its scope. This expansion covers an increasing keenness for data related to other care pathways along with the continuum and formal fiscal agreements for sharing the responsibility.

Healthcare Delivery and the Continuum of Care

The traditional healthcare continuum encompasses primary, secondary, and tertiary care and is quite requirements-centric, clear, and concise. However, it is based on the fact that there is an underlying ailment or injury. Although useful for treating individuals, it is not for those who wish to prevent health adversity. As per the World Health Organization (WHO), not even 2% of all healthcare resources are geared towards prevention. However, the contemporary continuum includes the preventive care dimension, as shown in Figure 1.

Healthcare in the U.S. is complex. What’s more to it is that the level of complexity is increasing as PHM is transforming the traditional hospital-focused approach into the modern continuum of care. PHM needs to be clinically more effective, safer, and more economical. It also needs to deliver more efficient outcomes using fewer resources. This is not an easy job in an acute care-oriented industry. So, in this evolving environment, how can an organization trigger quality improvements and cost reductions?

Well, the key is to systematize healthcare delivery step by step. To do so, it is first essential to comprehend the flow of care. Healthcare delivery’s structure is a conceptual framework illustrating how care delivery functions. It splits the existing complexity into a simple model containing domains and subdomains and the care flow among them, as shown in Figure 2. Through this illustration, it becomes easier to comprehend the care delivery process and find out gaps for improvement.

In Figure 2, care delivery starts with screening findings or symptoms. This results in a to a diagnostic examination. This is the time when providers need to decide the right treatment venue for the patient. The patient is then guided to one of three critical clinical management domains namely, clinic care, acute medical, and invasive. Figure 2 shows these as three vertical streams.

Each of these domains is split into subdomains. For instance, clinic care encompasses non-recurrent and chronic subdomains, acute medical includes Med-Surg and ICU subdomains, and invasive includes medical and surgical interventional subdomains. Here are how the care streams through these vertical domains:

That is the basic concept of healthcare delivery and care continuum. It as these significant decision points we need to systematize processes in a better way. This can be done by presenting evidence-based knowledge assets, which are indicated by blue and orange boxes in Figure 2.

The orange ones denote assets related to algorithms and criteria for prescribing the right tests and care. On the other hand, blue boxes indicate case-specific assets for managing the individual in inpatient and outpatient environments, utilizing substances, and implementing care in a standardized order in invasive and routine settings.

Using these assets is the key to make decision-making based on uniform, evidence-based medicine. Creating and implementing these strategies is likely to improve the clinical effectiveness and patient care safety. It allows identifying possible chances of improvement to boost quality, patient satisfaction, and control cost.

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