Population Health Foundations Solution

The Population Health Foundations analytics solution combines services with data and analytics technology to create a population health management (PHM) analytics starter set that can help organizations optimize their performance in value-based risk arrangements.  

The technology components are DOS™ Marts, Excel-friendly analysis tools that provide direct access to data for custom analysis, the Population Builder™: Stratification Module, the Leading Wisely: Population Health Module, and the Community Care Analytic Accelerator.  Solution services consist of Solution Optimization and a Population Health Management (PHM) Opportunity Analysis. Together, the elements of Population Health Foundations represent an essential resource for organizations that face financial risk for managing the health of populations—bringing a depth and breadth of insight and guidance for short- and long-term success in value-based care.

The problem

The transition to value is now an imperative—but population health work can seem overwhelming and risky.  And with inflexible, black-box point solutions, organizations continue to struggle to transform quality, cost, and delivery of care.

Our approach

Population Health Foundations is an accelerant to your organization’s success in value-based care. A robust expression of Health Catalyst's data-and analytics-first approach, this solution is a starter set that provides the transparent, configurable platform, tools, and analytics that allow you to use your data however you need to scale and prioritize. As part of the solution, our experts provides a side-by-side partnership to support success whether your organization is new to population health or has years of experience.

Benefits and features

• Integrate your claims and clinical data—and transparently transform raw data to deep data for faster, better insight into your value-based care business. DOS Marts aggregate, organize, and rationalize claims and clinical data and create a complete view of the care your patients are receiving across the continuum, in and out of network. Data flows seamlessly between the solution's technology components, ensuring that data, definitions, and population registries are diffused across your PHM workflow.
• Open up the black box with flexible, analyst-friendly tools. With our Excel-friendly tools, analysts have an easy, extensible entrance to in-depth analysis.
• Leverage intelligent tools to identify and stratify patients. Population Builder: Stratification brings predefined populations, standard risk scores, and machine learning models—all of which can customized to support your organization’s needs.
• Empower executives with robust views of your quality and financial performance. The Leading Wisely: Population Health Module gives you a single source of truth for financial metrics and a holistic view of performance in your value-based contracts. The module’s out-of-the box content is easily configurable to focus on KPIs that matter most to you—total cost of care, utilization in-and out-of-network, PMPM, etc. 
• Identify—and address—gaps in care. Community Care Analytic Accelerator makes it easy to track and manage care at the individual patient and provider level. Providers and organizations can identify gaps in care and drill down to the patient level, gauge adherence to best-practice screening and care, and support appropriate and timely interventions.
• Understand your data deeply to build short-, medium-, and long-term strategies for success. Our PHM experts provide side-by-side guidance for data and analytics strategy, design, and implementation—maximizing your investment in data and technology to support achievement in your specific payer arrangements.

Use cases

An organization in a commercial payer risk-based arrangement recently received a payer report showing that their PMPM is trending higher than target. Working with Health Catalyst, the VP of Population Health and her team use the Foundations technology to:

• Tune data logic, models and metrics to the organization’s contracts and covered populations—then explore data to determine PMPM drivers, e.g., diagnoses, in-and out-of-network utilization rates
• Identify and stratify high-utilizer patients and export cohorts into workflow tools; identify physician groups with a high concentration of patients with non-expected ED visits
• Plan interventions to address opportunities and configure dashboards to surveil KPIs

An ACO leadership team wants to identify performance trends that may affect their success in at-risk contracts. They need to understand whether they’re likely to hit their quality-reporting targets and where there are gaps. Further, they need to know the size of gaps: how many patients do they need to impact to hit targets? The team uses Foundations technology to answer these questions, helping them to identify care gaps, drill down to patient level for follow up, set priorities for improvement, and establish ongoing monitoring.