Achieving population health outcomes requires execution primarily in 6 principal areas, which can be captured within our vowels (or letters with a vowel sound). This mnemonic approach can aid organizations in avoiding many missteps that plague population health efforts. The 6 vowels and their corresponding areas are:
The first area is “Y,” or rather “why.” Why is an organization undertaking a specific population health effort? All too often, organizations mistakenly assume that everyone gets the why. This misconception sets the organization down the wrong track, or it can even prevent population health efforts from getting started. The need for preparation was captured by Abraham Lincoln when he said, “Give me 6 hours to chop down a tree and I will spend the first 4 sharpening the axe.”
Most organizations’ failure to prepare properly for population health efforts comes from the wrong assumptions that everyone gets why they are embarking on these efforts, combined with the enthusiasm to get started. The key is to spend the time to get everyone on the same page as to why a population health effort is being undertaken.
Of course, simply knowing the why is not enough to accomplish the task at hand. The organization must be set up in a manner to operate efficiently and effectively. Most organizations fail in their shared understanding of their focus areas and strategic goals. Decisions and requested actions are forced down from senior management, much like a chess player who maneuvers pieces around a board to achieve his or her objective; however, today’s organizations require a gardener’s approach. As General Stanley McChrystal described in his book, Team of Teams, master gardeners do not grow squash or beans, but rather they foster environments in which these plants thrive.1
Population health leadership requires a shared understanding of the focus areas and strategic goals that can drive a team to smart autonomy (Figure). This framework can further strengthen the core understanding of where the leadership should focus its attention to foster an environment to meet the shared goals and objectives of the industry and stakeholders.
This gardener approach is contrasted against that of a chess player. In chess, 1 person controls all the moves. A top-down controlled approach is possible because chess is an orderly game, with clear rules and alternating moves between players; however, in healthcare today, all stakeholders are moving multiple pieces on multiple fronts, without waiting respectfully for the next move. Medical decision-making unfolds in a fast and complex manner, making it far outside the control of a senior leader, yet most organizations continue with this approach rather than use a shared understanding cultivated by so-called gardeners.
“The horse has already left the barn” describes many identification efforts in population health. Patients are identified for care management efforts through claims data by pulling out high consumers of services well after the fact. The problem is that this approach represents patients who are already high consumers of healthcare, and, worse, where efforts to improve their care course are found far too late to see any benefit.
Instead, a more effective approach is to identify the rising-risk patients, namely, those who have not yet become high consumers of healthcare. If the care of these patients is managed properly, they could avoid becoming high healthcare consumers and instead follow a course of improved clinical and financial outcomes.
The Probability of Repeat Admission (Pra) and PraPlus screening tools identify elderly patients who are at high risk for increased use of healthcare services in the future. Pra is an 8-item questionnaire and PraPlus has an additional 9 items that evaluate an older person’s medical conditions, functional ability, living circumstances, nutrition, and depression.
The measures that are most effective in identifying these individuals do not come from complex calculations but rather from simply asking, “Would you say your health is excellent, very good, good, fair, or poor?” This is the first question in the Pra risk assessment. In one study, the Pra tool was a significant predictor of hospitalization at 12 months (Pra odds ratio, 6; P <.001).2 The benefit of this seemingly simple question in Pra is that it considers many aspects of a person’s health.
The engagement of stakeholders in population health efforts is another critical aspect that is often missed. The failure of patients and providers to be engaged in population health efforts leads to missed opportunities for improving clinical and financial outcomes and frustration on all fronts, but engaging these stakeholders is not always easy or straightforward.
Dan Ariely illustrates some common mistakes in decision-making in his book Predictably Irrational.3 The main thrust of his book is that individuals are systematically irrational in their personal, professional, and social behavior.3
Specifically, Ariely found that people who are happier do things out of a sense of social norm rather than because they are being paid. He gives an example of a school that attempted to decrease late-arriving parents by issuing fines; however, the problem only got worse. The fine created a market norm, leading to a paid-for transaction that legitimized the undesirable behavior.3 This highlights that organizations are often better served by engaging stakeholders through nonmonetary means, such as competition or a shared common goal.
Actions are where most healthcare organizations start and spend most of their efforts. These efforts are expressed through forced prompts that are often inappropriately timed and ineffective, which can result in provider burnout. As the fourth component of the Quadruple Aim of healthcare (ie, cost, population health, patient experience, and caregiver burden), caregiver burden has been recognized as a problem to avoid that requires careful management.4
Instead, actions need to be timed correctly and simplified. For example, a request for a patient to have necessary cancer screenings arrives on a physician’s computer in the middle of a typically busy day. Such a request may not prompt the appropriate action and will also cause great frustration to the provider. Ideally, such a prompt should be provided to the physician during the patient’s office visit, so that the request could be addressed in real time. An additional measure of success would include informing the patient immediately before the visit that these maintenance care items would be addressed.
Often outcomes are not considered, or the outcomes chosen as the target and measure for success are far too difficult to collect, are marred by inaccuracies, and/or are far too delayed to provide any value. Clinical outcomes can often be obtained from existing quality measures, although organizations may choose to adjust these measures to make them more specific to their needs. In addition to these quality measures, financial outcomes focused on the total cost of care are increasingly important, as payers shift financial responsibility to providers.
In the end, focusing on these 6 areas can ensure an organization’s success in its population health initiatives. It is as easy as simply knowing one’s vowels.
Author Disclosure Statement
Dr Stefanacci is an employee of EVERSANA, and Ms Banerjee is an employee of EVERSANA Engage.
- McChrystal S, Collins T, Silverman D, Fussell C. Team of Teams: New Rules of Engagement for a Complex World. New York, NY: Portfolio/Penguin; 2015.
- Salzman BE, Knuth RV, Cunningham AT, LaNoue MD. Identifying older patients at high risk for emergency department visits and hospitalization. Popul Health Manag. 2019;22:394-398.
- Ariely D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York, NY: HarperCollins; 2008.
- Feeley D. The Triple Aim or the Quadruple Aim? Four points to help set your strategy. Institute for Healthcare Improvement. November 28, 2017. www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy. Accessed February 17, 2021.