Population health management (PHM) strategies help organizations achieve sustainable outcomes improvement by guiding transformation across the continuum of care, versus focusing improvement resources on limited populations and acute care. Because population health comprises the complete picture of individual and population health (health behaviors, clinical care social and economic factors, and the physical environment), health systems can use PHM strategies to ensure that improvement initiatives comprehensively impact healthcare delivery. Organizations can leverage four PHM strategies to achieve sustainable improvement: Data transformation Analytic transformation Payment transformation Care transformation

1. Four Population Health Management
Strategies that Help Organizations
Improve Outcomes

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Population Health Management
Population health management (PHM) strives to
achieve IHI’s Triple Aim, including better outcomes
for individuals across communities.
Health systems working to improve healthcare
outcomes can meet their goals by aligning
improvement and PHM strategies.
This presentation describes how organizations
can use four PHM strategies to transform their
approaches to data, analytics, payment,
and care to improve outcomes and achieve
sustainable change.

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The Population Health Strategies
Outcomes Improvement Connection
While many organizations define population health
slightly differently, its core aim is to improve the health
and outcomes of individuals and populations while
improving efficiencies and reducing the total costs.
IHI references a definition from population health
researcher David Kindig:
Population health is defined as the health outcomes
of a group of individuals, including the distribution of
such outcomes within the group.”

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The Population Health Strategies
Outcomes Improvement Connection
Kindig goes on to explain…
…populations are often geographic populations
such as nations or communities, but can also
be other groups such as employees, ethnic
groups, disabled persons, prisoners, or any
other defined group.”
Regardless of how organizations
define population strategies, PHM
involves collaboration between
leaders in healthcare, politics, charity,
education, and business.

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The Population Health Strategies
Outcomes Improvement Connection
Factors that make up the complete picture of
individual and population health (Figure 1) span
health behaviors (e.g., tobacco use, diet and
exercise, and alcohol and drug use), clinical
care (e.g., access to care and quality of care),
social and economic factors (e.g., education,
income, and family and social support), and the
physical environment (e.g., air and water
quality and housing and transit).

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The Population Health Strategies
Outcomes Improvement Connection
Population Health
Management
Includes many factors
Robert Wood Johnson Foundation, 2014
Figure 1: PHM’s many factors
Health Outcomes
Health Factors
Policies & Programs
Health Outcomes (50%)
Quality of Life (50%)
Health Behaviors
(30%)
Tobacco Use
Diet & Exercise
Alcohol & Drug Use
SexualActivity
Access to Care
Quality of Care
Clinical Care
(20%)
Social/Economic
(40%)
Education
Employment
Income
Family & Social Support
Community Safety
Air & Water Quality
Housing & Transit
Environment
(10%)

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Four Population Health Management Strategies
that Drive Outcomes Improvement
There are four PHM strategies organizations can use to improve outcomes:
1 Data Transformation
PHM Leadership lays groundwork for a
high-functioning analytics platform.
KEY ACTIVITIES
1. Prioritize data sources, starting with claims data
2. Educate stakeholders on available data
3. Define supporting logic–like attribution
4. Invest in staffing
2 Analytic Transformation
Analytics leadership builds a structure to
identify and evaluate opportunities.
KEY ACTIVITIES
1. Ensure understanding of goals & requirements
2. Interview stakeholders for context
3. Assess data to identify quick wins
4. Synthesize and prioritize opportunities
5. Plan for ongoing evaluation and analysis
3 Payment Transformation
Financial leadership balances risk and helps
set a sustainable course forward.
KEY ACTIVITIES
1. Align PHM with financial plans
2. Look to benchmarks to set expectations
3. Ensure you are paid for the value you provide
4. Place utilization efforts carefully
5. Increase ability to understand true cost of care
4 Care Transformation
Clinical leadership identifies and implements
appropriate changes in care delivery.
KEY ACTIVITIES
1. Streamline your approach to quality measures
2. Optimize care management
3. Shore up primary care infrastructure
4. Seek opportunities for inpatient transformation
5. Ensure appropriate site of care
6. Develop patient engagement strategies

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Four Population Health Management Strategies
that Drive Outcomes Improvement
Using the four PHM strategies to provide the highest
quality, most appropriate, and most cost-effective care
for patients across the continuum, will improve
outcomes and bring both near and long term success:
NEAR TERM
 Meet contractual requirements in FFV contracts
 Remain successful in FFS business
LONG TERM
 Better quality of care across the continuum
 Lower costs
 Stronger organization
 Healthier community

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The Population Health Strategies
Outcomes Improvement Connection
Strategy #1: Data Transformation
Organizations must be able to prioritize and
integrate a multitude of internal and external
data sources to provide better transparency
into the population health journey.
This transparency helps organizations better
manage their networks, risks, opportunities,
and strategies to efficiently improve health.

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The Population Health Strategies
Outcomes Improvement Connection
Strategy #1: Data Transformation
The team working on the Alberta Health Services
population health initiative concluded that only
eight percent of the data needed for precision
medicine and population health resides in
today’s EHRs.
This highlights the need to incorporate not
only clinical data, but also data related to
health behaviors, social and economic data,
physical environmental data, claims data,
cost data, engagement data, and a variety of
additional sources.

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The Population Health Strategies
Outcomes Improvement Connection
Strategy #2: Analytic Transformation
Once organizations have the right data to identify and evaluate opportunities
for population health and improvement work, they will need an analytic
structure that can deliver several key capabilities:
The ability to produce a baseline understanding of the
target population. Further analysis can help synthesize
and prioritize opportunities. For example, to lower rates
of preterm births, health systems need to understand the
prevalence of early births in the population. Diving into
the data further may identify counties or geographic
locations where the prevalence is high and available
services are limited.

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The Population Health Strategies
Outcomes Improvement Connection
Strategy #2: Analytic Transformation
Once organizations have the right data to identify and evaluate opportunities
for population health and improvement work, they will need an analytic
structure that can deliver several key capabilities:
The ability to refine the definition of a population and
target the right people who could benefit from an
intervention. For example, to accurately capture the
number of children in a population with asthma, an
organization must look beyond diagnostic codes and
consider signs, symptoms, and pharmacy data.

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The Population Health Strategies
Outcomes Improvement Connection
Strategy #2: Analytic Transformation
Once organizations have the right data to identify and evaluate opportunities
for population health and improvement work, they will need an analytic
structure that can deliver several key capabilities:
The ability to identify improvement opportunities based
on variation in care. For example, identifying variation
related to adherence in prescribing best practice
medications for a specific condition.

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The Population Health Strategies
Outcomes Improvement Connection
Strategy #2: Analytic Transformation
Once organizations have the right data to identify and evaluate opportunities
for population health and improvement work, they will need an analytic
structure that can deliver several key capabilities:
The ability to understand the total cost of care across the
continuum versus the cost in a vertical setting (just the
hospital or just the clinic). For example, understanding
the total cost of care for an orthopedic procedure should
include pre-rehab, medications, supplies, inpatient costs,
post-rehab, medications, supplies, clinic costs,
readmissions, complications, etc.

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The Population Health Strategies
Outcomes Improvement Connection
Strategy #2: Analytic Transformation
Once organizations have the right data to identify and evaluate opportunities
for population health and improvement work, they will need an analytic
structure that can deliver several key capabilities:
The ability to plan for ongoing analysis to ensure
initiatives are impacting the identified opportunity areas.

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The Population Health Strategies
Outcomes Improvement Connection
Strategy #3: Payment Transformation
Organizations must transform their fee-for-service
payment models to better understand the total cost of
care and to balance the risk health that systems
assume under value-based contracting and
population health.
If organizations switch to value-based care models,
but don’t have the payment system to support the
shift, they can’t improve the health of individuals
and populations.
Systems must fully understand the total cost of care
and be able to look at risk contracts to ensure they’re
properly paid for the services they deliver.

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The Population Health Strategies
Outcomes Improvement Connection
Strategy #4: Care Transformation
Under care transformation, organizations optimize care
management processes and outcomes to support
individuals across the continuum of care.
For example, Cradle Cincinnati, an organization
committed to improving infant health in the Cincinnati
area, sought to address the rate of preterm births, and
associated deaths and complications.
By embracing the PHM strategy of care transformation,
Cradle Cincinnati identified smoking and inadequate
spacing between birth as modifiable behaviors
impacting preterm births (and the opportunity to save
more than $25 million per year).

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The Population Health Strategies
Outcomes Improvement Connection
Strategy #4: Care Transformation
Instead of targeting only women who were pregnant,
the organization approached the continuum of
pregnancy care by providing women in the community
who could become pregnant with a healthy pregnancy
education campaign.
Other care transformation improvement opportunities
include strengthening primary care infrastructure,
ensuring that appropriate care is given in the right
place at the right time, and improving engagement of
individuals and caregivers.

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Population Health Management Strategies
Improve Outcomes
On the next few slides are success stories
showing precisely how health systems are
actively using PHM strategies to improve
outcomes:
Opportunity Analysis Permits Successful
Execution of At-Risk Contracts
Turning Child Diabetes Management into
a Community Cause
Care Management: A Critical Component
of Effective Population Health Management
>
>
>

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Population Health Management Strategies
Improve Outcomes
Opportunity Analysis Permits Successful Execution of At-Risk Contracts.
As healthcare organizations confront a rise
in at-risk contracts, they increasingly work
toward the PHM goals of reducing
healthcare costs and improving patient
outcomes and experience.
Allina Health used its analytics platform to
combine several data sources, including
claims data, to identify opportunities to
decrease the total cost of care and improve
outcomes across the care continuum.

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Population Health Management Strategies
Improve Outcomes
Turning Child Diabetes Management into a Community Cause
Patients with diabetes are at a high risk for infections
and substantial complications, including the risk of
death from infections. Texas Children’s Hospital
identified gaps in diabetes care coordination in the
community.
With the support of an analytics platform, the TCH
initiated a coordinated community response to set the
standard for the management of pediatric diabetes.
As a result, it improved clinician knowledge of
pediatric diabetes by more than 26 percent and made
individualized school packets available in the EHR to
90 percent of patients.

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Population Health Management Strategies
Improve Outcomes
Care Management: A Critical Component of Population Health Management
Unprecedented changes in the healthcare payment
system are driving organizations to develop effective
PHM strategies.
Data-driven care management programs that target
high-risk and rising-risk patients can achieve
impressive results:
Up to 20 percent lower rates of hospitalization in
mature care management programs.
Lower rates of emergency department utilization.
Decreased costs.
>
>
>

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Population Health Management:
A Big-Picture Approach to Improvement
With PHM strategies, organizations approach
improvement from a broader continuum-care-
care perspective.
Instead of focusing improvement resources
on limited populations and acute care,
effective PHM strategies drive transform-
ation that addresses all levels of healthcare
delivery, including prevention and care
management.

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Population Health Management:
A Big-Picture Approach to Improvement
To begin the PHM journey and ensure that
PHM strategies truly impact outcomes
improvement, organizations must commit to
fully understanding the PHM strategies that
align with outcomes improvement and apply
them to areas with the greatest opportunity
for improvement.

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For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

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More about this topic
Link to original article for a more in-depth discussion.
Four Population Health Management Strategies that Help Organizations Improve Outcomes
A Guide to Successful Outcomes Using Population Health Analytics
Tom Burton, President of Professional Services
Three Essential Systems for Effective Population Health Management
Jared Crapo, Sales, Senior VP
Population Health Management: Implementing a Strategy for Success (white paper)
Dr. David Burton, Senior Vice President
Population Health Documentary Highlights Three Success Stories Transforming Healthcare
Leslie Hough Falk, Senior VP
How to Assess the ROI of Your Population Health Initiative
Bobbi Brown, Senior VP

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Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
Ms. Rimmasch brings over 28 years of experience in bedside care, as well as clinical and
operational healthcare management to Health Catalyst. She has spent the last 17 years
dedicated to improving clinical care including implementation of operational best practices.
Prior to joining Health Catalyst, Ms. Rimmasch was an Assistant Vice President at
Intermountain Healthcare responsible for Clinical Services (Pharmacy, Laboratory,
Respiratory, Case Management, Rehabilitation Services, Food and Nutrition, Patient and Provider
Publications, Clinical Operations for Imaging, Patient Flow, Pain Services, Continuum of Care) and was
integral in promoting integration of Clinical Operations across hospitals, ambulatory settings and
managed care plans. Prior to her role in Clinical Services, she served as the Clinical Operations Director
and Vice-Chair of Intermountain's Cardiovascular and Intensive Medicine Clinical Programs. She also
was the co-founder of and Principal in HMS, Inc., a healthcare consulting firm focusing on assessing,
developing strategies and implementing best practices for populations across the continuum of care
(physician offices, managed care, hospitals, and long-term care). Ms. Rimmasch holds a Master of
Science in Adult Physiology from the University of Utah and a Bachelor of Science in Nursing from
Brigham Young University.
Holly Rimmasch