Executive Summary

CareForAll is an insurance carrier with a Medicare Advantage plan in South Carolina.  In a routine study of all member emergency visit diagnoses, CareForAll finds an abrupt but then sustained threefold monthly increase in patient reports of numbness and tingling of both feet (peripheral neuropathy) beginning in September 2019 through February 2020 (last available data).   The Chief Medical Officer knows that the most common cause of peripheral neuropathy in elderly patients is diabetes but is uncertain if this is the explanation.  As a result, an informatics task force has been assembled to investigate and recommend actions.  The task force includes a regulatory/compliance officer, an analytics representative, a population health informaticist, and a population health nurse manager.  Together, these professionals will apply their skills to address the following: legal and regulatory issues that surround population health management (PHM) strategies and programs, big data analytics and how patient information can transform population health, including clinical aspects of patient care combined with associated factors outside the traditional boundaries of healthcare delivery and the effect on health outcomes (Health Catalyst, n.d.). These professionals will face many implications regarding successful implementation of a population management program.  To ensure better outcomes for the geriatric population, the CareForAll task force will need to address the following guidelines with a team-based effort to:

• Promote more well-informed diagnoses
• Support optimal treatment planning
• Provide a supportive workplace environment
• Improve outcomes through greater transparency
• Ensure continuity of care following discharge
• Engage and support patients after discharge

(HealthManagement.org).

Equally important, implementation of PHM programs for the geriatric population requires successful program designs, distribution mechanisms and proven access for older adults, funding through existing agencies (e.g., Medicare, health plans), and a comprehensive evaluation of the successful elements of a current PHM program (Tkatch, Musich, MacLeod, Alsgaard, Hawkins, & Yeh, 2016).  The focus of CareForAll’s investigation is to apply proactive applications of strategies and interventions to geriatric individuals across the continuum of their healthcare delivery in an effort to maintain and/or improve their health at the lowest necessary cost (Burton, 2013).  Thus, population health management strategies require a new way of thinking and a new way of executing the daily tasks of patient care (Bresnick, 2016a).  In the same way, healthcare organizations will have to cultivate innovative skill sets, which include care coordination, team-based approaches to distributing workloads, familiarity with data analytics, and a thorough understanding of quality reporting requirements (Bresnick, 2016a).  The task force will need to rely heavily upon the regulatory/compliance officer as a guide to ensure that the management of this population is conducive to legal as well as ethical requirements while meeting the program goals. Considering that population health management requires a change in the outlook and the practice patterns of health care providers, CareForAll will also need to embrace a new reimbursement model to support population health management and encourage providers to adopt a new way of delivering care and being rewarded (Loria, 2017).  Likewise, strategic planning plays an integral role as the task force relies upon the available data about this population to determine benefits and risks associated with the management of this patient cohort.  The importance of having an analytics representative and a population health informaticist on the task force is that they can assist in “breaking down barriers that prevent providers from using EHR data, claims data, demographic and socioeconomic data, and information from other providers for patient care improvements” while “assessing existing technology tools to maximize resources” (Bresnick, 2016a).   In addition, the population health nurse manager’s role is crucial in the prevention and management of geriatric disease prevention and management.  Given that public health nurses help to promote community health and safety and can work with whole communities, it is vital to have this individual on the team, as he/she is involved in the prevention, education, advocacy, activism, assessment, and evaluation of public health (Healthcare Management, 2019).

Introduction

The public health sector is unique in that its three core functions—assessment, policy development, and assurance, are the foundations for a community’s capability to address human needs (IOM, 2015).  Because these functions cut across all other areas and domains (e.g., housing, transportation, health care delivery), successful interventions that address population health management require that the public health sector incentivize and lead an interdisciplinary, team-based approach to the continual assessment of health status and needs (IOM, 2015). As a case in point, population health management programs are vital to the development and prioritization of plans and policies for addressing public health needs via research for disease prevention and the assurance of access to essential health services throughout the continuum of healthcare delivery (IOM, 2015).

Population health, by definition, is a “concept of health” characterized by both objective and subjective determinants and health outcomes of a population (Tkatch, et al., 2016).   Comparatively, “population health management is the aggregation of patient data across multiple health information technology resources, the analysis of that data into a single, actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes and seeks to improve the health outcomes of a group by monitoring and identifying individual patients within that group” (Tas, n.d.).  Consequently, PHM is one strategy to promote the health and well-being of target populations (Tkatch, et al., 2016). Considering that CareForAll has noticed an increase in patient reports of peripheral neuropathy but is unsure of the explanation, they have chosen the elderly as a target for their investigation and will recommend actions to improve the outcomes of this population and determine other key factors associated with the cause.

Benefits and Risks of Geriatric Population Health Management

The integration of both the subjective and objective concepts of health is necessary to consider in health management programs and research for older adults (Tkatch, et al., 2016). Given that eighty percent of what affects health outcomes is associated with factors outside the traditional boundaries of healthcare delivery, socioeconomic and environmental influences as well as health behaviors should be taken into careful consideration to improve the overall health of the population (Health Catalyst, n.d.).  While health care organizations benefit from encounter-based medicine practices, further investigation of population health via public health programs can solve many problems concerning elderly patients with chronic health conditions (Health Catalyst, n.d.).  One benefit to developing PHM programs for the elderly is that the gathering of public health data will help providers understand the complexities of care for this population and provide critical information to PHM care strategies for this group. Targeting these individuals and pinpointing patient outreach resources can improve patient outcomes while simultaneously reducing care costs (Gruessner, 2017).  Furthermore, the lack of consistent results for disease management programs highlights the need for a more comprehensive approach rather than targeting just one disease or health behavior, and a PHM program targeting the elderly can achieve this approach (Tkatch, et al., 2016).

On the other hand, there are certain risks associated with developing and sustaining a population health management program of this type.  For example, care for elderly patients is typically complex and these patients often require care from several different providers across the healthcare spectrum (Bresnick, 2017).  As a case in point, it will be necessary to work in multi-disciplinary teams, providing care remotely, and deploying well-defined pathways across care settings (Tas, n.d.).  This will require a change in workflows, shifting of processes, new roles and responsibilities, giving up previous incentives, and starting up new models of delivery of care and reimbursement methods (Tas, n.d.).  Speaking of reimbursements, new models will be required for PHM that aim at health promotion versus disease treatment (Tas, n.d.).  While healthcare is shifting from fee-based to value-based care, there is little incentive to implement preventative care strategies or prevent hospitalization and there is considerable lack of patients taking charge of their own healthcare (Tas, n.d.).  Another key barrier in developing a PHM program for the elderly is the transition to proactive, human-centric care, as “effective PHM requires strategies to reach the individual consumer or patient at all stages of life – early childhood, adolescence, adulthood and old age – rather than simply when they become sick” (Tas, n.d.).  Considering that the healthcare system is radically changing and the value-based system is more efficient and effective, PHM programs will require each patient as well as the entire practice or health system to be proactive and engaged (NRHI, 2017).   As a result, this radical redesign of the healthcare system involves not only clinical transformation from all aspects, but payment reform as well (NRHI, 2017).  This new design will require adequate review and adoption of rules and regulations provided by the government and related healthcare agencies.

Regulatory Requirements

Healthcare regulations are developed and implemented by all levels of government as well as private organizations and regulation plays a major role in the health care industry and health care insurance coverage (Grim, 2014).  The various regulatory bodies protect the public from a number of health risks and provide numerous programs for public health and welfare, and together, these regulatory agencies protect and regulate public health at every level (Grim, 2014).    To develop a PHM program for the elderly, CareForAll needs to consider several agencies for both mandated and voluntary participation as resources for information about industry changes, promotion of safety and assurance of legal compliance and quality services (Grim, 2014).  To illustrate, Nancy Grim, 2014 states that the Agency for Healthcare Research and Quality


(AHRQ) provides evidence-based research and is aimed at improving the quality of health care, reducing costs and addressing patient safety and medical errors.  Additionally, the Joint Commission on Accreditation of Health Care Organizations (JCAHO) “employs a system in which health care organizations are examined and then given a score of 1-100, with higher scores being better. These scores are important to health care organizations as they are a factor when determining reimbursement from Medicare” (Grim, 2014).  Likewise, the


National Committee for Quality Assurance


(NCQA) ensures the quality of managed care plans by providing standard and objective information about Health Maintenance Organizations (HMOs) (Grim, 2014).  Considering the PHM programs focus on public health, CareForAll needs to consider other regulatory departments that oversee other forms of public health regulation, such as Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the United States Agency for Toxic Substances and Disease Registry (ATSDR), and the Environmental Protection Agency (EPA) (Grim, 2014).  All areas of healthcare are subject to regulatory review and compliance, including CareForAll. For successful implementation of a PHM program, CareForAll will need to carefully review all polices, procedures, and regulations from the above entities to truly understand how best to address problems for elderly patient populations (Johnson, 2018).

Any healthcare organization opting to develop PHM programs for the elderly should specifically refer to the Centers for Medicaid and Medicare Services (CMS), as it oversees most of the regulations related directly to the health care system and is tied directly to Medicare for the elderly and disabled (Grim, 2014).  Considering that CMS primarily serves Medicare & Medicaid beneficiaries, CMS also “supports innovative approaches to improving quality, accessibility, and affordability, while finding the best ways to use innovative technology to support patient-centered care” (CMS, n.d.).  All things considered, payers as well as providers can develop PHM programs. At any rate, value-based care means operating under a very different payment system than volume-based models, and a quality payment program is needed to transform healthcare delivery (NRHI, 2017).  Additionally, it is through the Affordable Care Act (ACA) and other initiatives that the federal government is working to prevent and manage chronic conditions (NCSL, n.d.).  Furthermore, “the federal government funds federally qualified health centers, an integral provider of chronic disease prevention and management services for those who lack other access to care” (NCSL, n.d.).  However, “the ACA only deals with whether someone has insurance” (NRHI, 2017). In contrast, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) “is comprehensive and is bringing about the critical changes needed to improve quality and cost of care and provides assistance to all” (NRHI, 2017).  MACRA engages physicians by offering incentives to provide better care for lower cost (NRHI, 2017).  This system encourages the use of data and the development of incentive programs to help physicians align with the rest of the health community and move toward population health management (NRHI, 2017).  As a result, MACRA proves to be beneficial for PHM of the elderly as data associated with this cohort is influential in meeting quality health care needs at a reduced cost.

Impact of Informatics within Geriatric Population Health Management

The use of health informatics is essential to the successful development of a population health management program, especially when the program is geared toward a geriatric cohort.  Due to increasing population size and number of comorbidities among older adults, it is unrealistic to address their health needs solely on either an individual disease or condition-related basis; thus, a population strategy is required (Tkatch, et al., 2016).  Informaticists can can identify care gaps by analyzing data outside of traditional practices and expand their interactions with public health programs to tackle the most complex issues in providing care to those with chronic illnesses. By using big data and large sample sizes to better understand patterns of what is likely to happen to elderly individuals, informaticists can assist organizations in developing insights into how each unique patient is progressing along some of the most common disease routes and plan their interventions accordingly (Bresnick, 2016b).  For example, organizations can develop risk scores by examining large cohorts of patients with similar characteristics, extracting key clinical and lifestyle indicators from those cases, and informaticists can develop algorithms to chart how those factors influence ultimate outcomes. (Bresnick, 2016b).  This method “scores” or “stratifies” patients in such a way that places them into categories based on their clinical and/or lifestyle characteristics in an attempt to estimate costs, target interventions, gauge a patient’s health literacy and lifestyle choices (Bresnick, 2016b).  Namely, factors such as age, diabetes status, smoking history, cholesterol levels, and body mass index (BMI) contribute to poor health outcomes, and the risk scores computed from these factors could be used to develop PHM programs (Bresnick, 2016b).  Informaticists can use these risk scores to create predictive models to proactively identify patients who are at highest risk of poor health outcomes and who will benefit most from intervention (Bresnick, 2016b).  In this case, age is a significant factor and as previously mentioned, the geriatric population tends to show multi-factorial disease prognoses.  Consequently, it is important to stratify patients by risk in order to identify and address high-priority issues that impact larger groups of patients, which can ultimately affect the individual patient and can lead to ensuring that individual needs are met (Bresnick, 2016b).

In the same way, informaticists can provide support for nurse care managers and social workers by prioritizing care for the elderly in numerous ways. In light of the 2008 Institute of Medicine’s report, which indicates there is a shortage of health care workers for an aging U.S. population, an informaticist’s skills are particularly important to support all providers involved in public and/or private sectors (American Nurses Association, 2012).  Taking this in consideration, nurses and social workers alike can “design, implement, and participate in care coordination projects and practices that seek to improve patient outcomes and decrease costs” (American Nurses Association, 2012).  For example, nurse interventions can enhance patient decision-making, self-care management, and access to resources.  Equally important, informaticists can provide care coordination support within nurse or social worker interventions by mining and analyzing the data associated with care coordination projects.  Since CareForAll’s data encompasses patient-reported outcomes, social determinants of health, and activity-based costing, this will allow for accurate health management of elderly populations (Health Catalyst, n.d.).  Also, informaticists can measure the cost effectiveness of care coordination by addressing care gaps and assist in avoiding duplicate provided services (American Nurses Association).  Likewise, health informaticists can provide a way for knowledge about patients, diseases, therapies, and medicines to be more easily shared, which results in increased communication and coordination of care between providers and other healthcare facilities (HITC Staff, 2016).

While informaticists can assist health care providers within an organization, they can also work to enhance patient engagement opportunities.  Furthermore, informaticists can combine their clinical knowledge with their data skills to help ensure that patients have the information and tools that they need to make informed decisions in their care (UIC, n.d., a).  To illustrate, informaticists can make these contributions by ensuring complete and accurate electronic health records, shape patient portals and ensuring that they are integrated with other systems, investigate and leverage user data to identify challenges and create solutions associated with mobile applications, and analyze the mass quantities of information that are collected by wearable devices that track certain metrics (UIC, n.d., a).

Equally important, informaticists can assist with goal setting and evaluating population health management programs.  Organizations must first define and strategize how they want to implement PHM programs and what groups of patients they want to target to improve outcomes.  While measuring patient outcomes results in large data sets, the gathering of this information can be used to improve results in several ways (UIC, n.d., b).  For example, large data sets can be analyzed to improve certain processes, from medication recommendations to post-op care. (UIC, n.d., b).   Considering that healthcare is shifting from fee-for-service to value-based care and providers are awarded for quality of care versus volume of care, informaticists can review data and assist in eliminating unnecessary procedures, patient readmissions, and other costly practices without impacting the quality of care provided to patients (UIC, n.d., b).  Another way informaticists can assist with goal setting is by identifying patients at risk.  With the use of big data and predictive systems, identifying at-risk patients by addressing conditions before they become deadly helps to improve processes linked to barriers involved with quality patient treatment and care (UIC, n.d., b).  Moreover, informaticists that work with big data can identify processes that are inefficient, as well as those that are purposefully wrong such as identifying fraud and other forms of financial abuse (UIC, n.d., b).  The result of using such practices ultimately reduces variation in services provided, as “providers and other hospital staff will be able to ensure that the most optimal procedures are being used and can create the best chance for positive outcomes while lowering costs for both the patient and organization (UIC, n.d., b).  Furthermore, informaticists that analyze big data can impact not only immediate patient outcomes for today but can further important research of the future (UIC, n.d., b).  As a case in point, “the mass quantities of data available through health informatics give scientists more information to work with, providing clearer pictures of diseases such as cancer and diabetes, as well as determining the efficacy of drugs, imaging scans, nursing practices and other tools and procedures used in patient care” (UIC, n.d., b).  Given that unstructured data via mobile apps and wearable devices are becoming key factors in patient diagnoses, informaticists can leverage this data and use predictive modeling to assist providers in diagnosing disease and provide better options for treatment.

Key Informatics and Regulatory Recommendations

Health care informatics plays a key role the delivery of health care and the skills of an informaticist is vital in the development of PHM programs.  At the population level, informatics is important in improving care management of the elderly through the development of standardized processes, improved communication and strong care coordination, and evaluation of performance measures (HIMSS, 2014).  In the case of Group Y, they have recommended several components to strategically implement a PHM program for the elderly population to determine cause and effect of disease outcomes.  I agree with Group Y’s recommendations to integrate subjective components into their model.  It is imperative to consider factors outside of traditional health care to determine accurate delivery of health care needs.  For example, “addressing social determinants of health is important for improving health and reducing longstanding disparities in health and health care” (Artiga and Hinton, 2018).  Additionally, Group Y pointed out that using predictive statistical modeling to evaluate patients experiencing peripheral neuropathy can determine whether the condition is related to diabetes or if there are other sustainable factors associated with the cause.  As a result, “the informaticist could then help the program identify goals which would best utilize the resources of the program, while maximizing patient benefit, and reducing cost” (Group Y report, p. 10).  Moreover, I had recommended that the informaticist analyze, identify challenges, and create solutions associated with mobile applications, patient portals, and wearable devices that track valuable patient information.  Group Y has suggested that informaticists help to implement telehealth programs, which would increase patient engagement, facilitate more personalized education, and reduce costs for disease management (Group Y report, p. 10).  I agree with this strategy as implementing telehealth within the PHM program geared toward the elderly can increase healthcare access points and remove barriers associated with this at-risk patient population, improve care continuity by bridging care gaps, and engage patients in their own health outcomes (Greiwe, 2018). These recommendations assist the healthcare organization, or in this case, the CareForAll insurer in standardizing processes involved with big data, resulting in information that is usable and relevant to the population needs of the elderly.  Group Y has also taken good communication between providers and care coordination into account for their model.  As a case in point, “population-based informatics can be used to evaluate health outcomes and to support integrated care across the continuum” (HIMSS, 2014). This is the junction where the analytics representative, population health informaticist, and population health nurse manager can provide useful insights on how to proceed with development of the PHM program.  “Clinical informatics can facilitate complex chronic-care management through improving care between visits, promoting information sharing between clinicians, and identifying aggregate information that could improve care at the provider and system level” (HIMSS, 2014). Once the task force has assembled all necessary information and has established care coordination for this population, performance measures can then be implemented and evaluated.  Core metrics and methods will require further application by CareForAll to assess value and improve performance of the PHM program; thus, enabling more robust reporting across the industry and eventually leading to normative benchmarks (Hero, 2015).

Concerning regulatory recommendations, I would agree with Group Y’s suggestion to comply with the CMS Star Ratings program as well as other core quality measures that are a part of CMS.  CMS uses a five-star quality rating system to measure the experiences Medicare beneficiaries have with their health plan and health care system, where health plans are rated on a scale of 1 to 5 stars, with 5 being the highest (IBX, n.d.).   For example, star ratings for Independence Blue Cross (Independence) health plans are based on more than 40 quality measures within five categories that provide an objective method for evaluating health plan quality (IBX, n.d.).  The star rating program benefits patients and providers alike by raising the quality of care for Medicare beneficiaries, strengthening beneficiary protections, and help consumers compare health plans more easily (IBX, n.d.).   These star ratings give providers greater focus on preventive care and early detection of disease, participate in programs that help to manage chronic conditions, and better performance in Independence quality incentive programs (IBX, n.d.).  Patients can also benefit by “rating” providers and services, which helps patients have a better awareness of preventive services for early detection of disease, a greater focus on access to quality of care, and have an increased level of customer service (IBX, n.d.).  Participation in such programs enhances a PHM program’s chances for reaching the goal of improving health outcomes for the elderly population.  Considering that quality measures are tools that help measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems, it is imperative that CareForAll utilize these tools to gain the ability to provide high-quality health care, which relates to one or more quality goals for a PHM program for the elderly (CMS, 2019).  In fact, insurers like CareForAll have an advantage in contributions to PHM programs.  Due to their ability to access information about patients, CareForAll can leverage that information to boost their bottom lines and contribute to PHM data (Johnson, 2018). In addition to participating in the CMS Star Ratings Program, I would suggest that a model that CareForAll investigate for use within a PHM program is the Vermont Blueprint for Health.  The Vermont Blueprint for Heath aims to improve health and control costs by delivering comprehensive, well-coordinated care statewide (NCSL, n.d.).   “The Blueprint focuses on four broad areas: transitioning providers to the patient-centered medical home model, improving individual self-management of chronic conditions, developing health information systems and improving availability of community health care” (NCSL, n.d.).  CareForAll can implement a similar model as way to provide a wide array of options for the elderly population in terms of healthcare accessibility and assist these individuals with self-managed care opportunities while identifying cost savings based on healthcare data.   To ensure higher reimbursement, I would also include that CareForAll encourage Accountable Care Organizations (ACOs) to participate in Pathways to Success, which is part of the CMS Medicare Shared Savings Program (Holland, 2019). In this case, ACOs are mandated to share Medicare losses and gains (Holland, 2019). This incentive drives organizations to participate in population management programs; in turn, organizations can be rewarded while providing high-quality patient-centered care and can provide much insight to help ACOs save money and assume safer risks (Holland, 2019).  Additionally, participation can benefit patients that “meet evidence-based health care goals, such as keeping their blood pressure less than 140/90 mm Hg, or glycated hemoglobin (A

_1c

) at less than 7%, will receive financial incentives that would be in the form of health care credits, which can be used toward discounts on medications, health insurance, procedures, and co-payments” (Wu, 2019).

Conclusion

Population health management is a strategy that can improve health outcomes of any target population. The principles and best practices of population health management include data collection and management, as well as population monitoring and stratification; including patient engagement; team-based interventions, and outcomes measurement.  Given that geriatric population is complex and presents with multi-factorial symptoms and diseases, “careful consideration of all of the factors that influence and are affected by health reminds us that population health must be seen as the shared responsibility of health care providers, governmental public health agencies, and many other community institutions” (Stoto, 2015).  The challenge of managing a shared responsibility for this population’s health is that no single entity can be held accountable for their health outcomes (Stoto, 2015).  The assembling of CareForAll’s task force serves to improve this population’s health outcomes by integrating each professional’s skills by investigating factors associated with the increase of peripheral neuropathy and provide the best possible strategies to overcome the gaps in patient reporting.  By participating in quality improvement programs and following rules, policies, and regulations that govern healthcare entities, CareForAll insurers can implement this PHM program successfully.  With my recommendations coupled with Group Y’s recommendations, I foresee a great opportunity to assist the elderly in achieving better health outcomes resulting from the team-based efforts of all involved in the management of this population.

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