Recommendations

  1. Determine which populations you have total responsibility for outcomes and costs.
  2. Choose your population segment and learn about the root causes of high utilization and the assets that can be leveraged to improve outcomes.
  3. Determine which subgroups will be impacted by your enhanced care model.
  4. Secure initial and ongoing investment in improving care for your population.

1. Determine which populations you have total responsibility for outcomes and costs.

Establish a multidisciplinary leadership group with representation from key stakeholders to choose your population and lead the development of your enhanced care model.
Determine the population for whom your organization has responsibility for total health care costs and other health outcomes.
Tips and guidance for determining the population for whom your organization is responsible for total health care costs and other health outcomes:
  • Engage a core group of leaders who understand and support your organization’s enhanced care model and can dedicate staff time and resources to support this work.
  • Conduct a to find populations that align with the strategic interests of stakeholder organizations, to help secure ongoing leadership support and sustainability of your efforts.
  • Keep your organization’s vision and goals at the center of this work, and ensure that organizational leaders support the choice of your chosen population with complex needs and high costs.
“Coming from a health plan background, we think about Medicare, Medicaid and commercial populations, and knowing that each of those groups has different needs and they need different interventions. That was one of the big things for us, looking at them separately, as opposed to in one bucket.

We learned through experience that probably about 50% to 80% of the Medicare population is going to need complex case management, whereas for individuals with commercial insurance it is about 3%. We staffed according to population and the need.”Joann Sciandra, RN, BSN, CCM, Associate Vice President, Population Health, Geisinger Health Plan

 

jeremylong

“I think that choosing the population is very locally based. For example, some programs that I’ve seen, I think of San Francisco and a couple others, are really good from the standpoint of housing. At this point, 20% to 30% of our patients lack housing and they are literally on the streets or they’re in a shelter. We have been able to get a fair number of patients housed or we were with them when they became housed. Understanding the needs and what the intervention needs to be is really important in terms of choosing the target population and deciding, for example, whether or not you want to try and do addiction treatment within your walls or outside your walls, because that might also impact your selection of patients.”Jeremy Long, MD, MPH, Associate Professor, Division of General Internal Medicine with the Denver Health and Hospitals, Department of Medicine

2. Choose your population segment and learn about the root causes of high utilization and the assets that can be leveraged to improve outcomes.

Understanding the needs and assets of the individuals in your chosen population segment is core to designing effective and sustainable care systems. This is especially true for people who have complex needs and high health care costs. Review what you have learned about your population, considering clinical and utilization data, interviews with patients, and provider input: a 3-Part Data Review.

  1. Review all available data.
  2. Seek clinical input.
  3. Learn from lived experience by interviewing individuals in the likely chosen population.

rec2choosing

As you conduct your 3-Part Data Review, look for cost drivers and consider whether these drivers can be impacted by your enhanced care model. For example, some people have expensive care that should not be taken away, while others have experienced a physical trauma or an other event with time-limited effects. It’s key for your organization to understand the characteristics of the people who are at risk for accruing high costs in the future, using this information to then design an enhanced care model that specifically addresses their needs.

Organize the information using the 3-Part Data Review worksheet, or a similar format.

As CareOregon was developing their Health Resilience Program, they did a deep dive into there root causes. Review CareOregon’s three part data review process.

Review available data to learn about utilization and begin to recognize patterns of utilization among the people included in your population.
Interview care providers who work with your population to understand their perspective on the root causes of high utilization.
Interview 10 to 15 patients in your potential population segment to understand their perspectives on the root causes of high utilization.
Tips and guidance for identifying individuals with complex needs and high costs, and learning about the root causes of high utilization:
  • Knowing the characteristics of your chosen population is the start to understanding and selecting your population segment with complex needs and high costs.
  • There are several methods that you can use to learn about the needs and assets of your target population. Consider conducting a small series of narrative case studies or use standardized assessment instruments such as the HARMS-8 and the PAM.
  • Interview patients that are involved in your enhanced care model, as well as those that are eligible for your enhanced care model.

shelly-johnson

“Our goal is to reach the right population for our enhanced care model, so we used the inductive approach. That meant putting aside our assumptions about who we thought we were serving, and actually going out to meet people, hearing their stories and getting their input about what might work best for them. We started by screening people who came to TrueNorth, a social services agency in Newaygo County, to see if they would be willing to share their experiences managing their health. We would interview them and collect their stories as well as their feedback. The plan was that once we put their stories together, we would present them to our improvement team, who would then identify common themes. To ensure consistency in our process, we used tools we learned from the IHI Better Health Lower Costs Collaborative. The three main tools we used were the HARMS-8, the ACE, the PAM.

 

Our first round of interviews were an eye-opening lesson for us. We took a big swing at a big problem, and we missed. We started by using primary care as the initial entry-point for engagement with our target population. What we found was that these individuals are in more advanced stages of health crises. Strategically, we wanted to catch people before their health crisis flared up. So we took a different approach that has allowed us to get to where we are today. That approach involves interviewing individuals and seeking their feedback. As a group, we realized that we think we can walk into a room and know what the issues are. The reality is, we can’t just fix it. We’ll miss the mark. So we’re learning to slow down, take a step back, and actually involve the individuals that are going to be affected the most. It would have been nice to know this at the beginning of our work.” Shelly Johnson, RN, MPH, MBA, FACHE, Chief Operating Officer, Spectrum Health Gerber Memorial

3. Determine which subgroups will be impacted by your enhanced care model.

Your organization’s population with complex needs and high costs likely includes subgroups with different needs and assets, such as frail older adults, people experiencing homelessness, and people with multiple chronic or behavioral health conditions. Understanding the needs and assets of these subgroups is useful because it may suggest the need for tailored care approaches.

Review key themes from the 3-Part Data Review to identify potential subgroups of your population with complex needs and high costs.
Tips and guidance for determining which subgroups of the population with complex needs and high costs will be most impacted by your organization’s enhanced care model:
  • Begin to consider the care implications for each subgroup within the target population. The need for distinct enhanced care models is an indicator that additional subgroups could be useful.
  • Clearly describe your rationale for choosing distinct subgroups within your chosen population segment with complex needs and high costs.
  • Is your envisioned or current enhanced care model capable of addressing the unmet needs of your target population, or can the model be adapted to meet their needs? Can health care services play a significant role in improving the health of your chosen population?
  • Determine whether your organization currently has the competencies to serve the population with complex needs and high costs, or wants to develop these competencies. Ensure that your organization is willing to dedicate resources to help develop competencies where they do not exist.
  • Consider partnering with an academic or research institution to better understand the unmet needs and the assets of your chosen population segment with complex needs and high costs.

4. Secure initial and ongoing investment in improving care for your population.

Ongoing engagement with key stakeholders, developing a shared vision, and articulating expectations for results from the enhanced care model are all essential for securing ongoing investment in your enhanced care programming. A solid understanding of the desired strategic outcomes, the needs driving high utilization, and the available assets and resources can help your organization choose your optimal population with complex needs and high costs, and then develop and grow your enhanced care model.

Use the following steps to synthesize and frame your findings in ways that enable the team to advocate for long-term funding for the enhanced care model:
Tips and guidance for creating a path forward for securing initial and ongoing investment in programming for your population with complex needs and high costs:
  • Create a communication plan customized to key stakeholders; consider the use of language, focus of the interactions, desire for data, stories, or data and stories.
  • As new stakeholders join the work, engage with them as soon as possible to ensure there is a shared vision, alignment, and support for the enhanced care model, and to identify the need for modifications to the model if necessary.

alanglaseroff

“I learned to pay attention to the four audiences in order to sustain programs. One of the audiences is the clinicians who refer patients to the program. Another audience is the patients themselves because it turns out self-referral is by far the leading way we get patients, not because somebody else sends them to us. The third is institutionally, and the fourth is the health plan. The work never ends. You have to constantly engage these four groups. For example, every month we send a report out, including our enrollment and whatever new result we have; if we have some piece of data that we can parade out, we parade it out.”Alan Glaseroff, MD, Co-Founder, Stanford Coordinated Care