Tags: coordinated care , uniform high quality , affordability , redesigning care

Population health management. It’s a term you hear often, but what is PHM actually trying to do? Thousands of people across Partners are working together to achieve five goals:

1. Improve quality of care

PHM is implementing innovative programs across the care spectrum, with a focus on our most vulnerable patients, and measuring what matters most to them. We are achieving this goal through programs that create new care models such as Integrated Care Management (iCMP), Behavioral Health Integration, the Patient Centered Medical Home (PCMH), and alternative services for emergency care (Mobile Observation Unit). PHM also involves promoting richer data collection, such as asking patients about their experience – using Patient Reported Outcome Measures (PROMs) – to improve care

2. Slow down the overall growth of health care costs

PHM is about making sure patients have the right care at the right time to avoid unnecessary expenses.All our programs are geared toward reducing costs, from decreasing the need for hospital admissions with programs like iCMP, to shifting towards personalized medicine to decide whether or not costly surgeries are appropriate, and adhering to clinical guidelines to streamline care. Partners is also a Pioneer Accountable Care Organization (ACO), a federal initiative that has slowed the growth of health care costs for thousands of Americans.

3. Enhance care coordination

To make the complex health care system easier for patients, PHM is focused on improving the continuity of patient information, creating care management plans that the patient and the care team are committed to, and fostering relationships among providers.  A variety of post-acute programs (services provided after a hospital stay) bridge the gap between hospital and home.  They range from short-term Skilled Nursing Facilities (SNF), to home visits and even telemonitoring. We are also developing better ways for primary care doctors to coordinate with specialists to improve patient care.

4. Engage patients in their own care

PHM provides information and tools that empower patients to be more in charge of their health.  To assure that patients are well informed of treatment options, we provide interactive multi-media materials and videos to supplement conversations with providers and improve the decision-making process. Some of these materials include Vidscrips which are short videos  filmed by Partners’ providers about various health topics to help inform their patients about their conditions and possible treatments. Patients also have access to online communities where they can connect with other patients like them to share information and learn about their health.  

5. Use technology and analytics to support patient care

Technology is a cornerstone of PHM that allows us to monitor our performance and develop convenient ways for doctors and nurses to interact with patients and each other. Patients are able to video-chat with their doctors from the comfort of their own living room with the simple and secure Virtual Visits program. And primary care physicians can easily refer patients to specialists (with no long wait) through an online program called eConsults. Beyond the doctor-patient relationship, our investment in new technologies has allowed us to build a data warehouse that integrates data from multiple sources making it more accessible for research and to foster clinical improvement.

At its core, PHM is a host of coordinated activities, enabled by new approaches to payment, that are intended to improve patient care, lower costs, and increase efficiency for everyone. It’s still early, but it looks like the investment, and the work, are paying off.

This is the first in a series of articles about population health management (PHM) at Partners HealthCare.  Subscribe in the field below to ensure you don't miss future posts about the programs that comprise PHM.