Population health relies on provider collaboration, nurse coordinators, data sharing
There have also been some challenges in the timeliness of the data. A lot of our practices want information in real time. But everything doesn't happen in real time. So we're trying to see how we can speed up certain processes. We're making a major investment in a private health information exchange, which will help improve our ability to exchange information with our clinical partners. It's one of our long-term goals so we can improve our data and our population health capabilities and really work collaboratively with our partners.
FHP: How do you identify which of your members are high-risk? Do you have any predictive modeling methods in place?
Peskin: We use some proprietary tools to stratify risk. Our analytics department has been working on some very interesting predictive modeling and how to identify anticipatory risk versus rising risk.
FHP: It sounds like the care coordinators, like you said, are the lynchpins to your success. Are there any other elements that you would attribute to your ability to manage members with chronic conditions?
Peskin: There's no one person who can make all this happen. If you don't have the physician champion in the practice, it's going to fall flat. So you could have the best population care coordinator in the world, but if the physicians are disinterested or passive-aggressive, then it won't work. Culture is vital to the success of a practice's ability to embrace this notion of comprehensive, team-based care. So clearly, that's part of it.
Information data exchange is another important aspect of success. That's why we hold monthly webinars where we showcase best practices, have a biweekly newsletter and an annual summit. We invest a lot of time in what we call the onboarding process. But it's not just an onboarding and you're out on your way. So it's this education constancy that's key to our success. It's persistency.
FHP: What type of information are you passing on to these practices during the onboarding and education activities?
Peskin: There's a theme for each monthly webinar, whether it's how to better engage consumers, addressing folks who chose to go to the ER department for sniffles or low back pain, how practices have built their medical neighborhood or how to understand the analytics that we provide. We've done sessions on motivational interviewing. We tend to stay away from purely clinical areas, but we have done some updates on new diabetes guidelines. We respect and acknowledge that clinical areas are the domain of the clinicians, but we might bring in a subject matter expert on certain issues.
[Editor's Note: This interview has been edited and condensed for clarity.]