population health by the - ahp: advocates for human ......potential, inc. (ahp) has been improving...

ADVOCATES FOR HUMAN POTENTIAL, INC.CORPORATE OFFICE: 490-B Boston Post Road, Sudbury, MA 01776, 978.443.0055Other Office Locations: Albany, NY Chicago, IL Germantown, MD Pasadena, CA

For over 30 years, Advocates for Human Potential, Inc. (AHP) has been improving health and human services systems of care and business operations to help organizations and individuals reach their full potential. We

have a longstanding reputation for helping community providers and partners master the tools, processes, and mindset needed to succeed in the modern healthcare environment.

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Effectively coordinating care and services for defined populations is one of the greatest challenges in this era of population health management (PHM) and value-based reimbursement (VBR). It requires growing competency in population health data analytics that align with the interests of all payers.

This challenge is exacerbated by the multitude of data systems available and the variety of data types that need to be collected, stored, analyzed, and exchanged between stakeholders.

As complex as this may be, nobody can afford to stand still. The market is steadily evolving and the rigors of information management are only becoming more demanding.

Population Health Dashboards and Data-Driven Clinical Pathways Innovation

Population Health by the Dashboard Light

You Can’t Move Forward if You Only Look BackSpecialty networks of behavioral health and social services providers know that data can help them more successfully coordinate care for the people they serve. But most agencies are stuck looking in the rearview mirror at retrospective data to understand their population needs.

To truly move forward, agencies need to learn how to use available data to look ahead and make data-informed clinical pathway decisions for their unique populations.

Providers and their partners should seek to build dashboard tools - a Population Health Dashboard (PHD) - that automatically analyze data from across a variety of sources to identify patterns of care among individuals and populations and help them make data driven decisions.


AHP’s PHD provides interactive charts that enable you to quickly drill down on what you need to know.

AHP Population Health Dashboard (PHD)

The AHP Population Health Dashboard (PHD) approach and suite of tools are designed especially for providers and their partners who are interested and engaged in PHM.

COMMUNITY COOPERATIVE #1

MEDICAL CENTER #1

ACO #1

MANAGED CARE COMPANY #1

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BEHAVIORAL HEALTH PROVIDER #1

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COMMUNITY COOPERATIVE #2


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Five Lessons Learned While Dashboarding DataThese are five key lessons learned in the process of building and implementing data dashboards. For our complete tip sheet, please contact us at [email protected].

1. Teaming Is Essential

2. Timing Is Prime

3. Strategy Sets the Sights

4. Expectations Must Be Front and Center

5. Data Is Not Everything

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How Does a PHD Work? In the AHP PHD suite, all data, regardless of its format or type, is aggregated into one common “data store.” Our approach can capture vast quantities of patient data and make it available to improve individual and population-level client management through analytic and reporting tools. Our team will

� Build data stores on your SQL server infrastructure,

� Develop tables in your environs, and

� Layer in Microsoft Excel and Power BI tools.

The result: meaningful reports on key populations and key performance indicators such as emergency department and inpatient utilization that result from your interventions.

Our approach leverages the most commonly accessible, affordable, and popular software tools, keeping costs down while maximizing what your team can do with tools they’re already accustomed to.


- Identify and coordinate the data sources critically relevant to your patient population.

- Include information from payers, health information exchange(s), external provider(s), and claims data adjudicators.

- Establish data linkages and associations across disparate sources and formats.

- Unlock insights from multiple data sources through one user experience.

- Apply novel analytical processes within your existing technical infrastructure to present the data in a consumable and user-friendly format—no technological background needed.

- Conduct rigorous training and consultation.

- Develop a strengths-based curriculum for your staff to best serve your patients.

DATA ACQUISITIONDATA AGGREGATION AND NORMALIZATION

ANALYSIS ACTION

The PHD Development Process

A PHD Will Allow You to � Stratify risks among your

population and define potential impacts from interventions,

� Find groups of patients with common concerns,

� Outreach hard-to-engage patients and put them on their best clinical pathways,

� Coordinate care with other health system stakeholders to achieve best practices in team-based care,

� Establish baselines and benchmarks for VBR,

� Build a foundation for addressing social determinants of health and demonstrate successful outcomes, and

� Project or forecast trends into the future to better predict your risks.

Data-Driven Clinical Pathways Innovation Dashboarding data allows providers to stratify population risks according to select population traits and features, utilization, and claims. However, the real value is in what you do with that data once it is stratified.

True innovation occurs when providers use data to develop new and improved clinical pathways in the treatment planning process with patients, while care coordinators quickly and efficiently monitor and identify their success or need for adjustment.

With a fully functioning PHD, care coordinators can

� Include social service referrals and coordination based on SDOH data,

� Identify evidence-based practices that offer opportunities for integrated care and easier tracking and monitoring, and

� Understand and correct the failures of prior clinical pathways.

This emphasis on clinical pathway innovation, evidence-based practices, continuous quality improvement, and improved outcomes is the foundation for VBR. Whatever your VBR consists of, the steps you take now to prepare your organization with PHD are the right steps to ensure success in the future.

The Benefits of a PHDA PHD enables you and your team to fully utilize your data to improve care and identify patterns, trends, and issues within a population and community. We enable you to

� Measure and report on changes in trends;

� Monitor performance; � Identify where and how your clinical

pathways and continuum of care can better meet your expectations and the needs of your population, payers, partners, and network providers; and

� Build a case for a value proposition with payers and partners and secure incentives and other performance-related payments.

The Difference Is in the Training We succeed when your team feels absolutely comfortable maintaining, analyzing, and reporting at will out of the solutions we’ve designed and developed together. We build competency in PHM for all levels of staff through collaborative training.


AHP has implemented data warehousing and business intelligence projects with three different community providers in Central, Western, and South Coast Massachusetts. Through these health information technology (HIT) projects, the providers have improved quality, outcomes, and total cost of care (TCOC).

Data warehousing, analytical, reporting, and business intelligence (BI) tools are indispensable to providers, giving organizations the ability to correlate, analyze, and visualize the data that has been collected for years across myriad software and platforms.

For these three providers, AHP has been their guide in developing a data warehouse and BI tools. We have taught IT staff and others how to go from mountains of disparate data to a cogent and user-friendly set of utilities that they can afford. AHP does not sell any software or hardware. We advise, guide, and facilitate the process and the results belong to our clients.

As a result of our work, each providers has � increased their ability to collect, integrate, analyze, and

report data that will ensure that they can independently and continuously improve in quality, outcomes, and TCOC;

� Preserved their approach to person-centered, culture-specific care and services; and

� Demonstrated exceptional outcomes and the highest quality services to ACOs.

CONTACT US NOW for your free 30-minute consultation on how PHD can help your organization!

978-443-0055 [email protected] ahpnet.com

Revenue Assessment and Maximization AHP worked with a provider in Massachusetts to develop their strategy for billing/revenue cycle management, ongoing monitoring and key performance indicators, and the development of BI and dashboards. We began by analyzing business processes and the financial information comprising the revenue cycle, including claims submitted, claims paid, claims denied, and other claims data to determine this provider’s overall billing performance and the extent and cause of any weaknesses.

AHP established the nature and scope of revenue cycle breakdowns as evidenced by workflow and the available data. After detecting where the issues exist, AHP developed recommendations for correcting identified problems in billing operations, relevant clinical operations, and issues related to contracting.

AHP’s work with this provider strengthened their business operations in an actionable, sustainable way so they can ultimately increase net revenue and improve their clients’ experience.

The PHM in Action

Data Collection, Aggregation, Analysis, and Reporting to Support the Triple Aim

population health by the - ahp: advocates for human ......potential, inc. (ahp) has been improving...

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