Health Dialog Connections

5 Steps Accountable Care Organizations Can Take in Preparation for Implementing Population Health Management Programs

Accountable care executives working together as a team

As we know, Accountable Care Organizations (ACOs) are complex ecosystems and the implementation of new population health management programs can be daunting. New initiatives require time, behavior change, and workflow redesign. Here are steps your organization can take in advance of new program integration to maximize success.

  1. Define the ACO’s Population Health Goals: I entered “Population Health Management” into Google search and received 430,000 results in 31 seconds. How does your organization define Population Health? When identifying what your goals are for the next year, be specific and set a time for completion. Some examples are: 

    • Increase patient satisfaction by 15% in the next year

    • Reduce the number of avoidable readmissions post hospitalization over the next six months

    • Launch a patient portal by January 2016

Next, evaluate how these goals align with quality-based and value-based contracts. The closer they are aligned, the greater the chances of achieving and sustaining program success.

  1. Identify Administrative and Physician Champions: Health Dialog recommends that ACOs choose two people to lead the effort. These leaders should be, well respected and visible within the organization. They should also have the power to influence others on the clinical and operation sides of the organization. Champions ought to have a genuine interest in population health because they are likely going to need to “sell’ these new initiatives to all levels of the organization. In order to be successful, this position should be considered an important part of their broader roles and not simply something to be worked on when time permits. For this reason, we recommend that time is carved out in their schedules to devote to developing and promoting these programs. Lastly, the champions should co-chair the interdisciplinary team meetings discussed in the next step.

  2. Assemble an Interdisciplinary Team: Stakeholder engagement is essential to success; so invite representatives from different parts of the organization to the table. Include: clinicians, office managers, department clerks, and someone from IT, analytics, and security. Establish regularly scheduled meetings and set the expectation that attendance is mandatory.

    • One of this team’s first tasks might be to identify the kinds of population health management programs already in place. Health Dialog recently worked with an ACO that wanted to reduce the number of avoidable readmissions and asked the primary care practices to contact all patients discharged from the hospital within 72 hours. What they did not know was that patients with specific high-risk diagnoses were receiving transition calls from a special team of nurses from the Pulmonology Department and follow-up calls from the hospital’s case management department. No one knew about these patient outreach programs until patients started to complain about receiving too many calls after they got home from the hospital.

  3. Identify Potential Mentors and Establish Learning Collaboratives: Other organizations are out there that are meeting or trying to meet the same goals as your organization. Find them through professional organizations, conferences and community networks. Reach out to them; many are eager to share their lessons learned and words of wisdom. These resources can act as sounding boards and support systems, and they are free!

  4. Assess Analytic Capabilities: Developing analytic tools (e.g., patient target lists) and measuring outcomes are often challenging. Much of the data comes from the EMR. Not everyone within an organization documents the same way, which makes data collection a nightmare. Develop standardized documentation methods and teach all staff what information is essential to enter and where it should be entered in the EMR. Additionally, ACOs receive all kinds of data and reports from varying sources (e.g. health plans, pharmacies, laboratories). Catalogue those resources according to who receives them and how are they used.

What actions do you recommend an ACO take as it prepares for implementing population health management programs?


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