| “Population health management is founded on understanding population and subgroups’ clinical needs and utilization patterns and by being informed by tools and tactics to predict future risks and utilization. These are exactly the strategies we need to successfully reduce readmissions: Know your data and why your patients are readmitted; identify readmission risk factors, broadly defined; address and mitigate those risks; and ensure successful linkage to follow up and services in the community. Readmission reduction is a training ground for population health management capabilities.”
-Amy E. Boutwell, M.D., MPP, President, Collaborative Healthcare Strategies
Population health management provides a very good approach to target and reduce readmissions and many other healthcare utilization, quality and cost issues. While this quote starts out by stating that “Population Health Management is founded on understanding populations and subgroups’ clinical needs and utilization patterns” it deftly moves to “identify risk factors, broadly defined; address and mitigate those risks; and ensure successful linkage to follow up services in the communities”
The reason for a readmission may be due to non-clinical issues such as the community they returned to and their sociodemographic situation.
Its clear that the foundation for population health should include broader factors such as sociological determinants of health in addition to “clinical needs and utilization patterns” on the front end, but by stating “broadly looking at risks”, I assume this means looking beyond current clinical risk or utilization, and getting the community linkages, which are certainly required as part of the program to reduce readmissions.