Choosing Your Population


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“In order to run a successful program, you need to start by selecting a population for which you have a set of interventions that will achieve outcomes that are important to you in the time frame you want to achieve those outcomes. That’s a one line summary. I think about it in terms of program design. If you want to do your set of interventions, you need to think about the whole pathway when you select your patients. You want to sit down with patients that you’re worried about in your system and learn what’s important – who are the patients in our system, and how can we better understand them. These are all critical starting points.”Clemens Hong, MD, a primary care physician, and Medical Director of Community Health and Improvement for Los Angeles County, California


Why is this important? And what do we know?

  • People with complex health care needs often have multiple chronic physical or behavioral health conditions, coupled with functional limitations and unmet social needs. These multi-dimensional needs are often unmet by traditional health care models. When such needs remain unaddressed, people with complex health care needs are more likely to incur and maintain high health care spending. As a result, a small percent of patients often account for a large percent of health care spending. This dynamic was made public with the publication of the Hot Spotters article by Atul Gwande in the New Yorker January 24, 2011 and also used in Memphis, Tennessee-Utilization of Hot Spotting to Identify Community Needs and Coordinate Care In Memphis, TN.
  • For your organization to provide the most appropriate care to individuals with complex needs and high costs, it is important to have a deep understanding of the root causes for their high utilization. This understanding will help your organization target the people who are most likely to benefit from an enhanced care model.
  • Use a three-part data review to understand the needs and assets of your target population with complex needs and high costs:
  1. Review available data on the larger population to identify overall patterns (e.g., utilization, diagnosis codes, age, health insurance coverage) that may also impact the chosen population segment.
  2. Interview care providers to learn their perspective on the chosen population’s greatest needs and assets.
  3. Interview 10 to 15 individuals in the potential population segment to learn their perspectives on assets and needs.

Care Network of East Alabama interviewed patients using a tool called the HARMS-8 to learn how patients perceived their health status and the challenges they face in managing their health. The chart displays patients’ responses to self-reported health status.

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  • 8 patients take > 5 medications each day
  • 50% of patients were unable to afford medications at least once in the last 6 months
  • 75% of patients had at least 1 ED visit in the last 6 months
  • 7 patients rely on family/ friends for transportation to health care appointments
  • Choosing a population segment of individuals with complex needs and high costs, and learning about their needs and assets, is strategically important at the start of the development of the enhanced care model, and for its long-term sustainability. The decisions your organization makes and the information learned about the population with complex needs and high costs will improve the effectiveness of your enhanced care model, and will support robust decision making in all areas of your program.
  • Figure 1: Choosing your total population, your population with complex needs and high costs, and potential subgroups that will be impacted by your enhanced care model. Figure 1 illustrates how your organization can choose a population segment with complex needs and high costs whose total health care costs and other health outcomes may be impacted by your enhanced care model.1_4-mh_choosing-figure

Core recommendations

Determine which populations you have total responsibility for outcomes and costs.
  • Determine the population for whom your organization is responsible for total health care costs and other outcomes, such as health and experience of care. Your organization may have multiple patient populations to choose from, such as people receiving Medicaid-funded services, those enrolled in a Medicare ACO, or individuals within the geographic boundaries of a region.
  • Align your choice of chosen population segment with the strategic interests of your organization. You might choose to focus on the full population you care for, or on specific subgroups within the population such as those with risk sharing and shared savings. For example, your organization’s target population may include all people receiving Medicare-funded services, or may focus more specifically on Medicare beneficiaries enrolled in a Medicare Advantage Plan.
  • Detail to determine which populations you have total responsibility for outcomes and costs.
Choose your population segment and learn about the root causes of high utilization and the assets that can be leveraged to improve outcomes.
  • Systematically learn about your population to understand the root causes of high utilization, and choose the population with complex needs and high costs that is appropriate for your enhanced care model. An effective root cause analysis is the foundation for designing effective care models and may suggest potential care models to test with your chosen population segment.
  • As you learn about your chosen population segment, look for assets that can be leveraged to help meet the needs of the people served by your enhanced care model. Assets are resources that help people achieve and maintain health and wellness. They include community assets such as homeless shelters, the faith community, free medical clinics, walking trails, or other community resources. Other assets are more specific to the individual and may include health insurance, personal goals and motivations, family support, and other social support systems. When available, partner with existing resources rather than build your own.
  • Detail to choose your population segment and learn about the root causes of high utilization and the assets that can be leveraged to improve outcomes.
Determine which subgroups will be most impacted by your enhanced care model.
  • In your organization’s population with complex needs and high costs, learn about distinct subgroups of individuals within this population who have common needs and assets that can be best met by tailored care models. For example, the needs and assets (and corresponding care models) may differ among frail older adults, people with multiple chronic or behavioral health conditions, and people experiencing homelessness.
  • Your organization can find subgroups by talking with individuals within the chosen population segment to learn about their needs, assets, and how the health care system helps or hinders them.
  • Detail to determine which subgroups will be most impacted by your enhanced care model.
Secure initial and ongoing investment in improving care for your population.
  • The information that your organization is collecting will help you choose a population segment with complex needs and high costs and create a sustainability plan for your enhanced care model. Your organization can develop and grow its enhanced care model with a solid understanding of the desired strategic outcomes, the needs driving high utilization, and the assets and resources available to support the chosen population segment and the enhanced care model.
  • Detail to secure initial and ongoing investment in improving care for your population. 

How to get started with choosing a target population and learning more about their needs and assets

  • Form a multidisciplinary leadership group that includes organizational leaders and key stakeholders who can oversee and make strategic decisions about developing the enhanced care model for the chosen population segment. Ask this group to document the aims, mission, and values that matter to your organization, as well as the strategic business case for working with the populations for whom you have responsibility for total health care costs and other health outcomes.
  • Review data for your population from your organization’s health information systems, claims data, and other sources such as county health rankings and the community health needs assessment; interview care providers; and interview 10 to 15 individuals in the chosen population segment of complex needs and high costs to learn more about the people that use, or could use, your health care services and the root causes of avoidable high utilization.
  • The leadership group can use the information described above to select the population segment with complex needs and high costs that maximizes the impact of your enhanced care model and aligns this work with the mission, aims, and values of your organization.

Overall tips and guidance

  • Learn from others’ work, both within and outside of your health care system. Talk with or visit programs that are serving people with similar characteristics as those chosen by your organization.
  • Learn deeply about the needs, assets, barriers, and gaps that drive patterns of utilization from the perspective of your patients, their families, and their care teams.
  • Continue to evaluate whether you have chosen the right population segment with complex needs and high costs. You may need to redefine this population or identify smaller subgroups as more information is gathered during assessment of assets and needs in the chosen population segment.