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Leveraging Care Quality Navigator (CQN) for Health Plans

Population health management (PHM) is a holistic approach to healthcare delivery that focuses on improving a population's health outcomes. It encompasses various action plans aimed at addressing the health needs of specific groups or cohorts, analyzing data to identify trends, stratifying by risk factors, and implementing interventions to enhance overall well-being. This crucial approach to population health seeks to anticipate unmet needs, control costs, and deliver high-quality care. By observing trends and outcomes, organizations can identify the proper levers and improve the efficacy of preventative care. Facilitating this approach requires the right tools to enable payers and providers to proactively manage populations, measure results, and develop data-driven strategies.

However, PHM also presents its own set of challenges. These include:

  • Effectively integrating data from disparate sources.
  • Ensuring interoperability among different systems.
  • Engaging patients in their care.
  • Navigating complex regulatory environments.

Overcoming these obstacles requires innovative solutions like the Jiva Enterprise Health Management Platform that leverages advanced automation technology, predictive analytics, and collaborative workflows with low/no-code configurability. By addressing these challenges head-on with the right technology-enabled workflows and analytics, healthcare organizations can unlock the full potential of PHM and deliver higher-quality, cost-effective care to their communities.

What are PHM solutions?

Population health management solutions represent key components of the digital transformation landscape, driving the creation of digital tools aimed at enhancing the health outcomes of a population. This is achieved through the collection, analysis, and utilization of data on their health requirements, risks, and behaviors. These tools are crucial in supporting value-based care by offering preventive and personalized interventions, thereby reducing costs and improving quality.

Platforms are required to facilitate data integration and harmonization, enabling the collection, storage, and analysis of data from diverse sources, including electronic health records, claims, social determinants of health, personalized plan of care and patient-reported outcomes. Embedded with risk stratification and segmentation algorithms, these tools are designed to identify and prioritize high-risk, high-cost, and high-need populations for targeted interventions and care management.

Additionally, they facilitate the development of care coordination workflows, enhancing communication and collaboration among providers, patients, and other stakeholders. These workflows enable the delivery of personalized and preventive care plans, reminders, and educational materials. Quality measurement and improvement tools can monitor and evaluate the performance and outcomes of population health programs and provide feedback and incentives for continuous improvement.

Who are PHM solutions for?

Population health management solutions cater to a diverse range of healthcare organizations, including health plans, health systems, Accountable Care Organizations (ACOs), and Integrated Delivery Networks (IDNs). These entities seek such solutions to optimize delivery of care and improve outcomes for unique populations.

For payers, PHM solutions help identify and manage high-risk members, thereby reducing costs and maintaining the Medical Loss Ratio (MLR). With PHM advanced analytics, payers can craft high-performing networks by measuring and comparing performance across groups, facilities, or specialties. These solutions empower providers, improve member experience, and allow administrators to monitor care quality.

Health systems and ACOs utilize these solutions to enhance care coordination, reduce hospital readmissions, and successfully manage their value-based arrangements. Furthermore, integrated delivery networks and similar systems leverage PHM solutions to streamline care delivery across various points of care, leading to improved efficiency and quality of care.

Overall, these solutions empower healthcare organizations to proactively address the health needs of their populations, allowing organizations to drive incremental improvements benefiting their populations.

Which data are important to PHM?

To achieve improved outcomes from population health management, the solutions must have access to data from, not limited to, claims, point of service, community-based organizations, labs, medications, and more. Interoperability plays a key role in providing the best care coordination and management for the population. Therefore, having access to the data in real time is vital. Leveraging innovative technologies such as data streaming and AI predictions to transfer, capture, and analyze data from various sources is essential. Exchanging data with partners to facilitate closed-loop referrals and secure social care funding is also crucial for tracking outcomes collectively.

One of the biggest challenges is data disparity, which is unintentional. It is vital to tackle these discrepancies and ensure fair healthcare. Leaders need a comprehensive grasp of their data's accuracy and inclusivity to guarantee its positive impact on all patients. Only through this understanding can data-driven analytics and artificial intelligence genuinely improve healthcare delivery. Another crucial aspect is ensuring the security of data both in motion and at rest through the implementation of data encryption mechanisms.

Why use the Jiva Healthcare Enterprise Management Platform for PHM?

The Jiva Healthcare Enterprise Management Platform leverages:

  • Advanced data analytics.
  • Automated care coordination workflows.
  • A configuration-driven rules engine.
  • A robust library of clinical content, providing organizations with the right levers to improve outcomes.  

By harnessing the power of comprehensive data integration, sophisticated analytics, and robust reporting tools, Jiva empowers payer organizations to optimize care delivery and manage utilization. Its ability to delve deep into claims, social determinants of health (SDOH), EMR feeds, and other data sources enables the identification of key drivers of utilization and the stratification of populations based on risk scores. Jiva intelligently routes target cohorts to tailored care management workflows, ensuring individualized attention to specific needs and health goals. Dynamic dashboards and reporting tools offer invaluable insights into crucial performance indicators and enterprise metrics, facilitating informed decision-making and measurable campaign ROI. With pre-built visualizations for CMS Star ratings, CMS ACO Quality Measures, and NCQA HEDIS measures, Jiva supports optimal quality performance, empowering organizations to achieve their quality goals and associated revenue. Please contact us to learn more.