The Eye In The Sky

Objectives

• Describe the definition of population management
• Identify helpful and actionable data for medical care providers
• Describe how a system that feeds information downstream to care providers and upstream to managers of care can provide for cost effective high quality care

The Hot Spotter's Story

Chronic Disease Model

• Registry/ Decision Support
• Care Manager
• Measurement (screening to target)
• Prepared, proactive practice team
• Informed, activated patient

Moneyball'ing Healthcare

Population Health Management

• The provision of care and the monitoring of that care across a population (group) to detect trends and improve quality and outcomes
• Exemplar video: http://www.allscripts.com/solutions-current/sets/population-health-manageme...

The Population Health Game

• Two investigators
• Four patients
• 3 Providers, 3 Community, 3 Family, 3 Police
• Noise
• Scenario: Patients in need, high utilizing, need to get to help

Creating A Culture Where Data Matters

Take Homes

• We need to know more about our patients, in delivery systems and out of delivery systems
• We need to be able to manage that data
• We need to be able to share that data
• We need to partner to act on that data

What Kind of Data

Small Group Discussions

• Form groups from different departments
• What data, individual or aggregate, do you work with and how do you share it?
• How aware are different parts of the agency aware of the data you hold?
• How aware are community providers of the data you hold?

What Providers Need To Know

• Let's develop a list together of what medical and behavioral health providers need to know (data) to manage care effectively and efficiently
• What barriers exist? Does ABH have ways to overcome those barriers?

Data Should Be...

• Actionable
• Concise, digestible
• Accountable
• Tied to a process

Kinds & Purposes Of Data

• Quality improvement
• Population Tracking
• Reporting
• Care management

Don't Get Stuck

Methods of Data Collection

• Counting (manual)
• Extract from existing sources
• Create new data repositories/ strategies (survey)
• Start with easiest, most sustainable
• Ongoing, episodic or pilot-only collection

Data Analysis

• Basic statistics often suffice (sum, mean, STD)
• Simple tables in excel
• Significance of data is not always easy to determine (noise & poor data sources)

Good Consumer of Data

• Data source (sample composition and size)
• Data collection method
• Meaningfulness of the effect
• Other possible explanations for the observed results?
• Compared to what?

"There are lies, damn lies and then there are statistics." - Mark Twain