The growing emphasis on population health represents a sea change in the way medicine is practiced. A team-based effort is required to effectively meet the population health challenge of improving outcomes for groups of patients rather than a single patient at a time. Find out how private practices can focus on patients who will benefit most from a population health approach and direct staff to help efficiently deliver that care.

Fostering healthier communities

This episode of AMA Doc Talk explores how physicians can better serve their patients by thinking beyond the walls of the exam room.  

Care delivered to defined groups of patients based on their medical conditions is not only a sound clinical approach, it is also becoming central to practice sustainability. Health plans are switching from traditional payment mechanisms to value-based models tied to outcomes.

“Because of value-based purchasing, there is more incentive for physicians and practices to be sure that they are addressing the needs of their whole population of patients and not just those patients who take the initiative to present for care,” said internist Christine A. Sinsky, MD, who recently retired from private practice and is the AMA’s vice president for professional satisfaction. Population health success is closely tied to a shift from reliance on the physician to making the best use of everyone’s skills at a practice.

In-depth, actionable guidance on that score is available with the AMA STEPS Forward™ collection of open-access modules, offering innovative strategies that allow physicians and their staff to thrive in the new health care environment. These resources can help prevent physician burnout, create the organizational foundation for joy in medicine and improve practice efficiency.  

STEPS Forward is part of the AMA Ed Hub, an online platform that brings together all the high-quality CME, maintenance of certification, and educational content you need—in one place—with activities relevant to you, automated credit tracking and reporting for some states and specialty boards. 

Orientation modules on preparing your practice for value-based care and patient panel management provide private practices with the administrative basics for population health care. Condition-specific modules, such as managing type 2 diabetes and medication adherence, outline key clinical steps team members will perform.

Dr. Sinsky recently co-wrote an article, “Advanced team-based care: How we made it work,” published in the Journal of Family Practice. It details the experiences of Bellin Health system in Northeast Wisconsin in using team-based care for success with population health and other practice improvements.

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Know your patient populations

Before population health care can efficiently be delivered, the targeted medical conditions must be selected and corresponding patient names collected.

Systematically organize and treat populations by implementing a point-of-care registry. The system allows practices to efficiently “identify and care for patients with chronic conditions, as well as a means of tracking preventive care in your practice,” explains the module. The registry “can be integrated into your practice's electronic health record, a separate database program, or even a simple spreadsheet that is manually updated.”

Understand the community the practice serves to address the social determinants of health. The module describes these as the “conditions in which people are born, grow, work, live and age, and the wider set of forces and systems that shape the conditions of daily life.”

The six common domains are economic stability, neighborhood, education, food, community or social support, and health care system. When those factors are accounted for, practices can better tailor their clinical and support services recommendations.

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Build upon the traditional team

Team-based care for population health relies heavily on the staff members such as nurses and medical assistants. Two modules discuss particularly useful additions to the team.

Promote better patient outcomes with an embedded pharmacist at the practice. Among services that a pharmacist could perform is “pre-appointment medication reconciliation for the most complex patients, often over the phone a few days before the clinic visit,” according to the module.

“The pharmacist may also meet with individual patients to provide medication education, address barriers to adherence and answer patient questions,” as well as other patient and practice consultation services.

Improve treatment effectiveness by integrating behavioral health into the practice. Team members are likely to encounter—and should be able to signal screening for—patient depression, anxiety, and substance abuse.

Smoking or lack of exercise can detract from effective treatment. By increasing behavioral health awareness among team members and providing the right level of patient support, either from an embedded behavioral health specialist or consulting psychiatrist, practices will be better able to meet population health goals.

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