Population health management (PHM) is a system for managing the health of entire populations of patients—for example, those with diabetes, those at high risk for being readmitted to a hospital, those with both medical and mental health issues, or the elderly. The goal is to improve patient outcomes while controlling total medical expense by adding preventive services, chronic illness care and high-risk care management.

In the past four years, Partners HealthCare has developed a number of programs to proactively address the health needs of specific patient groups. These programs include the Integrated Care Management Program (iCMP) that coordinates treatment for high-risk patients across the continuum of care, as well as the team-based patient-centered medical home model for primary care that promotes coordinated, comprehensive care for patients. These programs were implemented in response to new payment models, such as Medicare’s Pioneer ACO.

Other components of PHM at Partners include the integration of behavioral health into primary care practices; mobile observation units to avoid unnecessary hospitalizations for conditions that can be treated at home; shared decision-making tools to educate and aid patients in making personalized medical decisions; and home-based palliative care services for patients near the end of life.

“We’ve had considerable success with our initial efforts, like iCMP and the patient-centered medical home, that concern primary care,” said Timothy Ferris, MD, who leads PHM efforts at Partners. “Now we are advancing a range of additional programs including those focused on specialty, post-acute and palliative care.”

The following are two examples of “PHM 2.0”:

E-Consults. This program features an electronic referral platform that allows primary care physicians to request an “e-consult” from a specialist. The ability to ask specific questions about a diagnosis or treatment plan can provide an alternative pathway for some patients and may be faster and more efficient than an in-person visit.

If an in-person visit with a specialist is required, the process can enable better preparation for the visit. Tests, lab work or other work-ups can be recommended and conducted prior to the visit. The program is live at BWH and MGH with 16 specialty areas and will soon be moving to community affiliates.

Patient Reported Outcome Measures (PROMs). This program measures the outcomes that matter most to patients—symptoms, functional status and quality-of-life, rather than, for example, how many days a patient stayed in the hospital.

“While scores and other quality measures are important to payers, they may not be as relevant to patients as quality-of-life measures are,” said Jessica Dudley, MD, BWPO chief medical officer. “Patients care about things like how quickly they were able to return to work after knee-replacement surgery or whether the ‘winter blues’ is really depression that should be treated.”

PROMs are measured through structured questionnaires using tablet computers in clinic waiting rooms and from home via Patient Gateway. They are being used by more than 20 medical and surgical specialties at more than 50 locations across Partners. PROMs leaders expect to have collected 75,000 surveys by the end of 2015 and 150,000 by the end of 2016. By focusing on objective measurements of symptoms and function, providers can use routine PROMs data collection to augment their ability to provide patients with the best clinical outcomes. By comparing data among institutions, aggregate data can be used to improve quality, aid in public reporting and eventually orient care toward the outcomes that matter most to patients.