Population Health Management eBook

Population Health Management

Creating And Launching A Population Health Management Campaign

The previous chapters described how to simplify population health management (PHM) through highly automated data capture, analysis and reporting, as well as patient interventions to save time and improve outcomes. Although advanced PHM technology is essential to enable this automation, healthcare organizations need to set themselves up for success by creating targeted and effective patient outreach campaigns focused on their care quality and financial goals.

With some simple and strategic preparation, however, organizations and care managers can enjoy the efficiency and insight of automated reporting and interventions across any population.

Identifying And Prioritizing Goals

The old saying about how "you can't improve what you don't measure" is highly applicable to effective PHM. That is why the first step in establishing your PHM campaign strategy is to determine the organization's most urgent or significant goals. It is tempting when starting out with PHM campaigns to create as many as possible and determine which one is most effective. A better strategy is to create one or two campaigns and then refine and improve them until the response rate and other results reach the desired objectives.

Many organizations, for example, want to reduce all avoidable readmissions across their enterprise, which is both a clinical quality and cost-reduction goal. Other institutions may wish to focus on readmissions for specific populations of high-risk patients, such as those with congestive heart failure (CHF), chronic obstructive pulmonary disorder or pneumonia, all of which are conditions susceptible to penalties under the Hospital Readmission Reduction Program from the Centers for Medicare and Medicaid Services.

The healthcare organization will then need to set associated benchmarks in the PHM technology platform for continuous monitoring, analysis and reporting. For example, if the goal is to reduce readmissions within 30 days for only CHF patients, the care manager will need to check those boxes within the software.

Identifying The Patients

Once a broader care and financial goal is established, it is recommended care managers narrow the PHM platform's focus to track tightly focused groups of patients under that goal. Since the technology would be seamlessly integrated with the organization's electronic health record (EHR) and other information systems, selecting patients across broad criteria is simple. For example, perhaps the organization may only want to monitor CHF patients ages 65 and older who have been recently admitted to the hospital. Conversely, providers may choose to narrow the focus to CHF patients with other designated chronic conditions because they pose a greater risk for readmission. All of these criteria and others can be tracked through campaigns.

Additional Criteria Could Include Any Combination of:






Residence location


Emergency department utilization


Positive or negative response to automated interventions


Recent test results


Any clinical identifier, such as lab value, medication, diagnosis


Payer or value-based care payment program

As organizations gain experience in these areas, multiple campaigns can be run simultaneously to monitor more populations or as payers introduce new value-based care payment programs. This scalability and flexibility extends to the type of outreach that can be delivered through advanced PHM technology platforms, as described in chapter 5: text message, phone call, and postal mail, all based on individual patient preferences.

Descending Levels of Campaigns

The goal of the outreach campaign is to have patients drop-out or "descend" to lower-risk thresholds. Descending the risk profile means the patient will continue to receive active monitoring through the PHM platform, but automated outreach activity and reporting would be less frequent, depending on the care manager's preferences or the goals of the organization.

Perhaps the most exciting aspect of conducting these campaigns is that accuracy only increases over time. The greater amount of data and patient activity captured in the platform helps the PHM technology better predict behaviors and outcomes. As a result, the platform and care managers can more proactively respond to trends and improve patient outcomes.

The next and final chapter offers some advice for expanding and improving a PHM program for long-term success, and how PHM can help organizations evolve with the continuing changes in value-based care payment.
InteliChart Chapter 5

Save time with automated data capture, analysis and reporting.

Chapter 7 InteliChart

Evolving operations from episodic to holistic and year-round.