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Kyruus Blog

Transition Management: Where the population health management rubber hits the road

This post was written by George Pace, Kyruus' Director of Client Development

A health system CEO once told me that anyone who tells you she knows what “population health management” means is lying. While I wouldn’t use similarly strong language to make that point, I have had many conversations with health system and health plan leaders about “population health management”, and through those conversations have come to understand that we do not nearly have a uniform definition of what the term even means. The absence of a uniform definition for population health management can be attributed to market variability, i.e. my population is different from yours, and therefore implies a different approach to managing it.

Variability aside, there remain fundamental guiding principles that constitute the essence of population health management, the primary ones being that effective population health management requires: 1) the ability to accurately define patient needs and; 2) effectively marry those needs to interventions that yield the best possible result at the lowest possible cost. Otherwise stated, the ability to transition patients across multiple care settings and multiple providers swiftly and seamlessly is critical to effective care management, which begs the question, how are we doing that today? Sadly, the answer is not encouraging.

Most often, patients are referred to specialists based on very blunt criteria: location, availability and specialty being the three most prevalent. What’s worse, in many instances, patients are referred to specialists based on relationships (“Go see Frank – he and I went to medical school together and he’s fabulous!”). Oftentimes, this referral methodology can lead to misdirection and, subsequently, less-than-optimal care. And while patient/provider match-making at this level may be efficient, i.e. quick and easy, it is by no means effective, which is why regardless of which market you study you will find the co-existence of long wait times for specialist appointments and schedule capacity among providers. When you consider the fundamental goals of population health management, namely to defend the perimeter of the acute care setting against unnecessary admissions (or re-admissions) and mitigating the decline in the health of the chronically ill, you begin to see why wait times are not merely an inconvenience or threat to patient satisfaction, but a threat to effective population health management.

The answer, while hardly easy, is simple: we need a smarter way to match (patient) demand with (provider) supply so that, instead of ending up back in an emergency department or inpatient unit, patients can receive more valuable care: less costly and equally, if not more, effective.

So why doesn’t this happen today? Because it is shockingly difficult and burdensome for providers to transition patients to the right follow-up, despite their being inclined and perhaps even rewarded for doing so. We need a way for providers to access the inventory of available care in their communities/markets with a level of specificity that enables decision-making about referrals, and subsequently connect their patients with the right providers real-time. This would enable care coordinators and primary care physicians – the “quarterbacks” of population health teams – to make informed decisions in support of the higher-order goal of caring for patients in the most effective and least costly available settings, and out of the most costly setting – the hospital.

Topics: Physician Referrals Physicians Referral Misdirection Referral Management Hospital Analytics Hospitals Patient Access