Population health and clinical integration bring providers together for better care

Discussing the system's clinical integration efforts are: Amanda Skinner (left); Heather Malcolm, RN, care manager, Medicine/Pulmonary Unit; and Ian Schwartz, MD, executive director, Care Management.
Discussing the system's clinical integration efforts are: Amanda Skinner (left); Heather Malcolm, RN, care manager, Medicine/Pulmonary Unit; and Ian Schwartz, MD, executive director, Care Management.

The terms "population health" and "clinical integration" might not be familiar to everyone, but once Amanda Skinner explains how they work, she finds many people understand the need for both.

Population health and clinical integration are different, but related, concepts, said Skinner, executive director of Clinical Integration and Population Health for Yale New Haven Health System.

With both, different healthcare providers — primary care and specialist physicians, hospitals, diagnostic facilities, rehabilitation centers, home health services and others — work closely together to share patient information, coordinate services and engage patients in their own care. Care is focused on prevention, successfully treating patients who do develop problems, and managing those with long-term health conditions.

Population health and clinical integration differ from the "episodic" care common in the US, according to Skinner. With episodic care, for example, a physician might advise a patient with diabetes to have a blood sugar test and adjust his or her medication dose. Once the patient leaves the office, the physician may not know if the patient acted on these recommendations.

"With episodic care, you visit the doctor, you get a plan and you leave. It's one episode of care," Skinner said. "You might or might not follow through on the doctor's plan. It's up to you."

In supporting clinical integration, Yale New Haven Health is helping to build a system focused on actively helping patients get the care they need, when and how they need it. Using technology like Epic and other types of systems, providers will share information and use care coordinators and care management programs to help patients understand and execute their plans of care. For example, a care coordinator might call the patient with diabetes to discuss his or her medication change and send a reminder letter to get blood work done.

"Clinical integration and population health are moving us from providing patient care solely during doctor visits to meeting patients' needs as they move through the continuum of care," Skinner said.

To build the foundation of population health and clinical integration, physicians with Northeast Medical Group, Yale Medical Group and the New Haven Community Medical Group have been collaborating for over a year. Work groups have generated ideas to enhance care for patients with diabetes and cardiovascular disease and improve care transitions for patients who move from one healthcare setting to another.

In YNHHS's new position, Skinner is building on that foundation, providing the structure and support to create a comprehensive, clinically integrated provider network and develop population health programs.

Beyond the benefits patients will experience in a large network of connected providers, population health and clinical integration will enhance care quality and efficiency, reduce costs and help YNHHS and its delivery networks meet healthcare reform goals, said Christopher O'Connor, executive vice president and chief operating officer, YNHHS.

"The federal government is no longer reimbursing healthcare providers for each episode of care they provide to Medicare or Medicaid patients, but tying reimbursement amounts to care quality," O'Connor said. "With population health and clinical integration, the providers in our clinically integrated network will use best practices and provide coordinated, evidence-based care to all patients. That means better patient outcomes, and, ultimately, a healthier community."