NCQA’s New Module of Population Health Management

Population Health Management (PHM)

Beginning to prepare for an NCQA Accreditation Survey, requires one to see that NCQA  now has a module of Population Health Management (PHM). Why is it important to know about the population in an organization or in a practice? What does Population Health mean?

Population Health is an approach to health that attempts to improve the health of one’s population or looking at a group of individuals or patients with certain conditions or diagnosis and working with those patients to have better outcomes.

To begin at the practice level, staff must be able to gather data on their patients or work with their payers to obtain data on the patients within their practice. Examples could be a gap in care report for those patients in need of an A1C, mammography/cervical cancer screenings or a lipid panel.

Identifying your patients with gaps in care and managing their health helps patients obtain the needed care for preventive services as well as monitoring their chronic conditions.

Closing care gaps for patients in a practice allows the care team to better manage their populations, decrease admissions to hospitals, manage aspects of their chronic conditions and reduce visits to the Emergency Room and Re-admissions to the Hospital. In addition, coordinating care for patients among Primary Care Physicians (PCP), specialists and all transitions of care helps with closing the gaps in care. Better management also provides for decreases in the cost of patient care. When looking at care gaps, be sure to include care for medical, behavioral health and medication management as well as social-economic issues which all impacts on the patient’s outcomes.

The members within a health plan now require looking at all types of populations, not just those who are sick. Organizations will now support all members in the services they need for a healthy lifestyle. PHM takes in both healthy members and those in care management. Organizations, during their preparation for an NCQA survey, will develop a PHM Strategy, identify their population, connect them to appropriate services and educate members on healthier lifestyles. NCQA will expect organizations to design their PHM programs around four basic areas: 1) programs in keeping members healthy; 2) programs to manage members with emerging risks; 3) programs for patient safety or outcomes across settings and 4) programs to manage multiple chronic illnesses of members. Examples of such programs within organizations may be cervical /mammography screening, flu immunization, diabetic individuals with an A1C greater than 9, program for members with prescription alerts and reducing admissions for members with asthma and diabetics.

Knowing your patients and the ability to collect data on their care is critical for managing your patient’s health. Always involve the patient or family caregiver to make healthy choices when managing their health decisions.

About the Author:

Jean Lockington, MA, RN, PLNC, PCMH CCE has worked for Professional Services Network as a consultant for many years. She has over 25 years’ experience working as a Senior Executive in managed care. Her areas of expertise include quality improvement, regulatory compliance, new business development, process improvement and accreditation preparation.

About Professional Services Network, Inc. 

Professional Services Network, Inc. (PSN) works with clients nationwide in the search and recruitment of experienced healthcare professionals in managed care and clinical roles for temporary assignments and direct hire opportunities.  Additionally, PSN’s consultants work with organizations and providers seeking accreditation or re-accreditation with URAC or NCQA. For additional information regarding our services contact us at 301-460-4089 or email us at [email protected].