Advancing the Population Health Improvement Model
The Care Continuum Alliance promotes a proactive, accountable, patient-centric population health improvement model featuring a physician-guided health care delivery system designed to develop and engage informed and activated patients over time to address both illness and long term health. Care Continuum Alliance members believe that managing health requires the active, integrated involvement of all health care professionals coordinated with the patient and their caregivers and families. We offer these principles to describe the elements of this fully-connected health system, leveraging teams of care providers, focused on proactive, coordinated, quality health care.
The population health improvement model highlights three components: the central care delivery and leadership roles of the primary care physician; the critical importance of patient activation, involvement and personal responsibility; and the patient focus and capacity expansion of care coordination provided through wellness, disease and chronic care management programs. The convergence of these roles, resources and capabilities in the population health improvement model ensures higher levels of quality and satisfaction with care delivery. Further, coordination and integration are important tools to address health care workforce shortages, individual access to coverage and care, and affordability of care.
The accountability for delivering and coordinating appropriate cost-effective care and the credit for achieving targeted improvement and goals for population health must be explicitly recognized and proportionately rewarded. To this end, the population health improvement model envisions optimization of both physician office practices and other services that improve population health, where demonstrated to add value. To best achieve this, payers, purchasers, patients and their advocates and other members of the health care team must promote and ensure appropriate reimbursement schedules for cognitive services, care coordination, referral activities and adherence to desired processes, such as the use of evidence-based clinical guidelines.
Key components of the population health improvement model include:
The population health improvement model:
Accountable measurement of progress toward optimized population health should include:
* * *
The Care Continuum Alliance supports this population health improvement model to provide the elements of a fully-connected health care system to provide all members of the health care team essential tools to ensure proactive, coordinated, quality health care.