Photo by Daniil Silantev |Unsplash
“Where is your health care system on its journey towards population health?”
That’s the question Marie Cleary-Fishman, BSN, MS, MBA, CPHQ, Vice President of Clinical Quality for the American Hospital Association’s Health Research & Educational Trust (HRET), posed to participants at a session during the 2017 IHI National Forum. Cleary-Fishman, and Forum co-presenters IHI Chief Operations and North America Programs Officer Trissa Torres, IHI Senior Project Manager KellyAnne Johnson, and Public Health Institute Senior Investigator Kevin Barnett, are part of the five-stakeholder Pathways to Population Health coalition.
During the session, once everyone was given a primer on correct population health terminology, groups were then asked to identify one plan per table and answer a set of questions: What would a balanced portfolio of population health efforts look like? Where would you be in one year? In 2020? What assets/roles could be leveraged? Which stakeholders will be engaged? At the end of the planning session, teams traded their best practices and ideas with each other.
“Folks were really forced to think together,” recalls Cleary-Fishman. “The groups were diverse — acute, non-acute, health care organizations and community partners, established and new organizations, large and small, urban and rural.” For example, in one group, there was a representative from ambulatory care working with someone who was about to open the doors on a new hospital. Sessions participants had the chance to practice working with a range of people with varying perspectives to reach a common goal — just as they hopefully would when they returned home.
The theme of the session was that hospitals and health systems must partner with others in the community — including social service organizations and other hospitals — to make lasting improvements in population health alone. “Partnerships with other health systems and community organizations drive us to really look at health and well-being,” says Cleary-Fishman. “If we think of that as the outcome, then all of this work is the vehicle to help the people in our community achieve that outcome.”
When organizations focus on population health together, there can be tangible benefits to the surrounding community. For example, when a patient is readmitted, the hospital may experience a reimbursement penalty. However, what if that hospital identifies a group of patients with diabetes who are readmitted because they can’t get access to the right food? If they partner with a local grocery store or a community program (such as Meals on Wheels) to address that need, they may see a reduction in readmissions and penalties. They may then reinvest those savings in their community to achieve overall health and well-being.
“Population health is not something new or additional for hospitals and health care systems,” Cleary-Fishman noted. Data is already being collected about individuals; new elements can be added — like social determinants of health — and that same data can be used for populations. “Hospitals and health systems are already working to improve the health and well-being of individuals,” Cleary-Fishman pointed out. “Reach out to key partners in the community to do the same for the broader population of your community.” Action plans can then be created with community partners to enhance the scope and reach of hospitals and health systems.
“You’re working to help your communities already,” Cleary-Fishman says. “Don’t be afraid to tweak a few things that can allow you to learn more and do more.”
Marie Cleary-Fishman, BSN, MS, MBA, CPHQ, is Vice President, Clinical Quality for the American Hospital Association’s Health Research & Educational Trust.
To learn about how to make practical, meaningful,
and sustainable advances in population health, join the Pathways to Population Health journey.
You may also be interested in:
A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost
IHI/NPSF Patient Safety Congress (May 23-25, 2018 in Boston, MA)