Building Population Health

Shifting to value-based care requires a new model of healthcare operations and focus on new population health goals. For many hospitals and health systems this means a systematic transformation.

In late 2015, Davis Health System (DHS) began building the infrastructure for population health. Today, they're more confident that their investment and operational commitment is paving the way for growth opportunities that support greater coordination of care, reduce clinical variances, and promote economies of scale.

Family practitioner Catherine "Mindy" Chua, D.O. is the DHS Chief Medical Officer and Physician Champion for the Population Health program. She was chosen to lead the physician alignment component of the program, which includes participation in a newly formed ACO. As the impassioned physician champion, she is driving engagement from the medical staff to achieve the goals of the triple aim: improve the patient experience of care, improve population health, and reduce costs.

Any thoughts on the first year of the program's development?

I think we're ahead of the curve. On a national scale West Virginia hospitals and health systems still lag behind, but I feel good with our progress in 2016. Larger healthcare systems have been working on population health infrastructure for years. When Vance ]ackson joined Davis Health as CEO last year he brought experience and a clear vision for population health. That certainly helped us organize and prioritize steps.

What does it mean to be the Physician Champion for Population Health?

The population health model supports positive change for the way we all (patients, providers, and hospitals) think about healthcare. My role is to help define and implement the change that brings value. I'm committed to making healthcare more beneficial for our patients, our physicians and Davis Health System.

Where do you focus your efforts?

Physician engagement is both my biggest opportunity and my greatest challenge. Fundamentally physicians are distrustful of change, me included. We fear loss of autonomy. My role is a liaison between "change" and the medical staff and providers. I'm currently participating in an AHA-AMCA Fellowship that provides valuable learning and networking on physician engagement. At the core of this Fellowship is data supporting Population Health methodologies like cost reduction, care coordination, improved patient care, and increased physician and patient satisfaction. Having access to the data and resources is vital to me because providers are more apt to support new programs when backed by evidence.

What challenges have you faced in the first year?

We always like to see the immediate effects of our efforts but population health is a long-term commitment. This is especially evident in the technology and predictive analytics of population health. Tracking specific disease conditions and individual patients requires being able to aggregate data from many different sources and we're not able to do that yet. We're struggling with how to accumulate and track data across these different settings.

Why is the shift to Population Health Management important?

Population health is being driven by Medicare Payment Reform so you might think it's about chasing metrics and compromised care. However, value-based care can improve the quality of patient health. It's not episodic, it's over time... if we are doing a good job caring for the patients, then the metrics will fall in place. To succeed under new payment methodologies like MACRA we need to begin making changes now including implementing new clinical quality measures and determining how to fund further measures, utilize resources, incorporate meaningful use and implement clinical practice improvement activities.

Where do you see your program in the next 1-2 years?

It's hard to say because healthcare is ever-changing. We'll see population health evolve at all levels and we'll continue to adapt to change. Our goal is to create healthy communities and much of what we accomplish in chronic disease management today will support better health in the generations of today and tomorrow.