Lesson 13 Discussion
Team based care is one of the foundational elements to population health. Per the AAMA Population Health reading, what is team based care and why is it important?
Introduction As the U.S. health care system increasingly prioritizes the value of services provided to patients and establishes reimbursement models that incentivize efficiency and quality, our physician training programs must similarly adapt. In primary care graduate medical education (GME), physician training programs have recognized the importance of prioritizing new models of primary care to ensure that the future primary care workforce is adequate in supply, skilled at meeting the needs of patients and populations, and ready to meet the demands of high-value care. These skills are the “building blocks” of a high-functioning primary care practice and are outlined in a 2016 AAMC report, High-Functioning Primary Care Residency Clinics: Building Blocks for Providing Excellent Care and Training.1 Population health management (PHM) is one building block of high- functioning, high-value primary care but is inconsistently understood and operationalized in practice and training settings. As we train the next generation of physicians and as our delivery system shifts to focus on managing populations and individuals, a framework for approaching this work is necessary, particularly in residency training. On June 25-26, 2018, the AAMC sponsored the meeting “Population Health Management in Primary Care Residency Training Programs.” Held in the AAMC’s Washington, D.C., offices, the meeting included representatives of the AAMC, University of California, San Francisco Center for Excellence in Primary Care (UCSF CEPC), and Centers for Disease Control and Prevention (CDC) and leaders from seven residency programs in family medicine, internal medicine, and pediatrics that were identified as exemplary in key aspects of PHM. The meeting was funded in part by CDC’s Division of Scientific Education and Professional Development, Centers for Surveillance, Epidemiology, and Laboratory Services, through cooperative agreement 5 NU36OE000007. The AAMC asked the UCSF CEPC to assist with meeting planning and facilitation, based in part on their efforts to investigate high-functioning primary care in GME practice sites, including PHM. The lessons from these prior visits were captured in two AAMC reports, one in 2016 and one in 2018.1,2 The purpose of the meeting was to describe best practices in PHM in primary care residency teaching practices, with an emphasis on how residents are trained. Intended for residency program directors, this report summarizes the components of PHM and offers vignettes describing how several of the seven participating residency programs TERMINOLOGY The following terms represent the consensus of the meeting participants. Clinician refers to physicians, nurse practitioners (NPs), and physician assistants (PAs) — those professionals authorized to make diagnoses, prescribe medications, and bill for clinical services provided. Population health management (PHM) refers to a systematic approach to ensuring that all members of a defined population (e.g., all patients receiving care at a primary care practice or all patients receiving care from their personal clinician) receive appropriate preventive, chronic, and transitional care.3 PHM also helps providers identify and address health care inequities among subgroups within that population and includes screening and assistance for those clinic patients facing barriers to optimal health such as food insecurity, insufficient income, precarious or unsafe housing, and domestic or neighborhood violence. PHM broadens the traditional approach of focusing only on individual patients. Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.4 These groups are often geographically contiguous populations, such as nations or communities, but can also be groups such as employees Association of American Medical Colleges3 implemented these components. The vignettes may provide ideas to residency practices that wish to improve their PHM competency. The seven programs described in this report vary significantly in the practice of PHM. Similarly, programs that wish to develop a PHM system may do so in different ways, applying either a narrow, targeted approach or a more comprehensive approach to adopting the elements of PHM into their practices. The descriptions provided here can be applied in a variety of combinations and illustrate how these elements are operationalized in diverse clinical settings. Meeting participants identified 10 interrelated requirements that comprise a comprehensive PHM system. Figure 1. The 10 interrelated requirements of a comprehensive population health management system. of a company, ethnic groups, disabled persons, prisoners, or any other defined group. Population health includes the broader determinants of the health of people within a defined population and addresses health inequities within subgroups. Population health goes beyond specific clinical metrics and considers what interventions in addition to medical care are needed to keep a population healthy (e.g., access to jobs, healthy food, safe environment, reasonable income). Meeting participants often referred to PHM as focused on the “small p” population and noted that it addresses the needs of clinic and clinician panels, while “large P” population health is concerned with populations not necessarily associated with one clinic, clinician, or health system. The distinction between PHM and population health is analogous to the distinction between health care and health. Population Health Management Panel management Patient risk- stratification Care management Addressing social determinants of health Ensuring health equity Complex care management Self- management support Data infrastructure Te am -b as ed c ar e C o m m u nity engagement Association of American Medical Colleges4 Foundational Elements 1. Data infrastructure: Data infrastructure is the organizing, tracking, reporting, and making transparent demographic and clinical data within the electronic health record (EHR) and specific data registries. 2. Team-based care: Team-based care is the process of creating teams with a variety of health professions represented, including physicians, nurse practitioners, medical assistants, pharmacists, social workers, and others. 3. Community engagement: Community engagement requires an understanding of local community needs and assets and the development of intentional partnerships with community members near the clinic, including residents, community-based organizations, and health departments. Key Activities 4. Panel management: Panel management ensures that all patients in a population (the entire clinic’s patients or the panel of one clinician or one team) have their routine evidence- based preventive and chronic care tasks performed in a timely manner, including recognizing and addressing inequities. This process includes addressing “care gaps” and actively engaging patients at risk of poor health outcomes while in the clinic and between visits. 5. Patient risk stratification: Risk stratification is the process by which patients are placed into subgroups that are determined by the area of focus of the clinic. 6. Care management: Care management for patients with chronic conditions, often done by nurses or pharmacists, assists patients with behavior change and medication management. 7. Self-management support: Self-management support helps patients acquire the knowledge, skills, and confidence to participate actively in the care of their chronic condition or for preventive health measures. 8. Complex care management: Complex care management is a program to identify high- needs and high-cost patients and systematically address these patient needs using a team- based interprofessional approach. 9. Addressing social determinants of health: Addressing social determinants of health requires systematic efforts to meet patient’s social needs that may affect their well-being, as identified by the care team and denoted in the EHR. 10. Ensuring health equity: PHM can be fully realized only if an equity lens is applied to ensure a reduction of health disparities while improving health outcomes for the patient population. Addressing health inequities among a population requires stratifying clinical data by factors such as race/ethnicity, language, gender identity, sexual orientation, ZIP code, and insurance status to identify any gaps in health outcomes within subgroups of the patient population. The rest of this report further describes the foundational elements and key activities of PHM and concludes with an overview of how to integrate these principles into a primary care residency. Association of American Medical Colleges Teaching Residents Population Health Management November 2019 5 1. Data Infrastructure Individual patient care requires data — from the history, physical exam, lab tests, and imaging tests. Similarly, PHM relies on health systems and teaching clinics’ collecting, aggregating, organizing, tracking, and reporting demographic and clinical data. Data are critical to tracking quality measures that primary care practices are expected to collect. Increasingly, health system reimbursement partly depends on quality performance metrics that in turn require data. A teaching clinic’s data often derive from the data infrastructure of the health system in which the clinic is embedded. Usually an information technology (IT) specialist or IT department at the larger health system builds the data system. For teaching clinics, establishing a close relationship with the health system’s IT specialist is essential. Smaller health systems, for example Federally Qualified Health Centers (FQHCs), may have an IT specialist within the clinic. IT specialists are not clinicians, so a data-savvy clinician within the teaching clinic must work with the IT specialist to build a data system that serves the clinic’s PHM needs. If a clinic’s health system lacks an engaged and accessible IT specialist, the teaching clinic’s leadership needs to make the case for the resources that are needed to hire one. A key component of a teaching clinic’s data system is the data registry. Registries are lists of all patients enrolled in a clinic or empaneled to a clinician, with patient-specific clinical, social, and demographic data. In the past, EHRs lacked a registry function and many practices used stand-alone registries. Increasingly, EHR systems feature registries populated from patient charts and laboratory results. Registries may be comprehensive, providing data on multiple chronic conditions and preventive care. Alternatively, registries may be disease-specific, providing data on diabetes, depression, or asthma, for example. Once the registry is built, the IT specialist and data-savvy clinician(s) work together to create daily, monthly, or quarterly reports for clinicians and staff at the teaching clinic. The reports can provide data by clinician and team so that individual clinicians and teams can see and discuss whether their preventive and chronic care metrics are improving and whether there are disparities among subgroups. The reports may also aggregate the data longitudinally (run charts) by metric so the clinic can judge its