Home Health is Getting Savvier in Population Health

Over the last few years, population health has become somewhat of a buzz word in the home health care industry. However, not all organizations define population health—and how they approach it—the same way.

North Carolina-based Well Care Home Health, which launched in 1987, is a fully integrated post-acute care provider that has taken on population health management across all its patients. Home Health Care News caught up with Robin Kipple, Well Care’s director of population health and clinical integration, to learn how the organization is setting up population health programs to serve the 40 counties in North Carolina.

When Kipple came on board with Well Care in August 2017, determining a definition of population health and setting standardized goals across the organization was a top priority. In addition, as Well Care is involved in a number of alternative payment models, including accountable care organizations (ACOs) and the model 2 bundled payments for care initiative (BPCI), figuring out the population health needs of clinical partners was also essential to consider.


How does Well Care define population health?

We have developed a value proposition for ACOs and figure out what are their pain points and [what is] our vision of pop health. Every post-acute care provider out there has a different version of population health and what it means to them and their organization. So, we’re trying to figure out what are the unique needs of the ACO, the unique needs of the patients they are serving, and how do we take our expertise and align that with our goals.

Specifically, when we speak to how Well Care has defjned population health, we’re looking at it as total patient mangement. We actually coined that phrase. We really look at the patient and how they enter into our organization, and make sure we have what the patient needs, from wellness to death, to meet their health care goals. We are not the experts at every touch point that the patient may have or the transition the patient may go through, [which is why we are] really forming the relationships with the experts to transition the patient at the right time in their care cycle. We really feel like that’s important, to be bigger than ourselves and have a footprint bigger than ourselves.

More generally across the health care space, where are we with population health management? What is the status quo?
It seems like it’s a buzz word—everybody is getting their feet wet and trying to figure out what it means to them.
From the seat I’m sitting in, it seems a little chaotic because people are trying to figure it out. It’s hard when you have one foot in fee-for-service and one foot in value-based care at the same time. Each organization seems to be defining population health and what that means to them. It’s really a big step. It’s taken several months to find out what population health means to us and our partners, and really [it’s about] our patients and how to serve them better. It’s not just a definition for the organization, but for the patients to have a better outcomes. [We’ve got to] take a step back— that’s what people are trying to do and trying to figure out what it means to their organization.
What is the role of home health care in population health management?
With the total patient management, we’re really defined by acuity. We know there are going to be populations of patients that have a similar set of circumstances or clincial symptoms. When a patient comes into our organization, we are defining that by their acuity level and building a system that tells us the acuity of the patients. But we can’t stop there. The patients can have similarities, but individuals, people have differences. So, what are the differences each patient has that sets them apart? We’re using technology to fgure out the acuity of our patients when the patient enters into the Well Care system, and using Health Recovery Solutions (HRS) to help us with some of the identifications and some of these touch points. We’re also looking at the differences of populations and circumstances of patients through social determinants of health that really let us be specific to the individual. And using tech to identify those social determinants.
We’re also using technology to look at high-risk indicators to the patient’s risk. What are the points our population of patients are at risk for a poor outcome? We define the ultimate poor outcome, besides death, as a [hospital] readmission. We are judging the readmission costs to a health care system as $10,000—to someone. We’re looking at time points where patients are at highest risk and what touch point is appropriate to mitigate that risk. We also have to keep cost in mind, not all patients need in-home visits or hospital visits or physician visits. Those are the most costly visits; we’re looking at what touch point is the lowest cost that can yield the highest outcome. Technology is helping us identify those points to decide what touch we may need.
What I’m seeing today is a positive direction, but not enough to make a trend. But hospital rates going down for the organization. Margins are increasing. We are looking at cost, which is important for a population health program [and] the triple aim.
What are the top population health opportunities in 2018? Top challenges?
Analytics would be the biggest challenge I’ve faced so far. Trying to figure out what do we want to measure, how do we want to measure it and what does the data mean. Sometimes, you can get into data overload—too much data is too much data. And it’s expensive, so not all organizations have the money for robust analytics programs.
Population health gives every organization the ability to think outside the box, be innovative with care and think about patients in a different way than we ever have before. Today is the day to shine with clinical development and it’s very exciting what population health means. For the first time ever, I can go to an ACO or physician group and talk about what to do together to make an impact. We’re holding hands around the table, sharing strategies. Before, people would be scared to talk about what they are doing in fear of someone stealing it. Now, we want people to steal ideas and think differently with us.
Where does population health fit into alternative payment areas, like value-based purchasing or managed care, or even Medicare Advantage?
With insurance companies and MA, we are having to figure out who is the expert at the right time, and if there are opportunities for MA to offer by tapping into their resources with the payers and our clinical partners. We’re looking at the spend for the patient and who could yield the best outcome for the patient. I’m not sure we have looked at insurance providers this way; we’re just getting our feet wet now, but it’s very exciting.
But again we made the decision early on we are not going to treat an MA patient any differently than another patient.  Put the patient in the center and yield the outcomes. Keeping financials in mind, keep the patient in center, and everything else falls into place.

Written by Amy Baxter

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