DMAA Releases Landmark Population Health Improvement Principles, Model

WASHINGTON, D.C.—DMAA: The Care Continuum Alliance today released landmark principles for population health improvement and a model for an integrated, physician-guided delivery system for population-based chronic condition care.

The DMAA paper, "Advancing the Population Health Improvement Model," describes the elements of a fully connected health system that leverages teams of care providers focused on proactive, coordinated, quality care across all stages of disease—from general prevention and wellness to individual care for people with existing conditions.

"These principles mark a milestone in the evolution of DMAA and population-based care," DMAA Chairman William C. Popik, MD, said. "Today we reaffirm, unequivocally, the paramount role of the physician, as well as the valuable contributions of population health professionals, to high-quality, coordinated care."

The DMAA population health improvement model comprises three core 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 expanded care coordination capacity provided by wellness, disease and chronic care management programs.

"The patient—and the patient-physician relationship—are at the center of this new model, supported by proven strategies developed through population-based care to keep the well healthy, prevent disease and minimize the ill effects of chronic conditions," DMAA President and CEO Tracey Moorhead said. "This strength of this model lies in its comprehensive, coordinated team approach."

The DMAA model emphasizes the need to explicitly recognize and proportionately reward cost-effective care that achieves targeted improvement goals for population health. To best achieve this, payers, purchasers, patients and their advocates and other members of the health care team must promote and ensure appropriate reimbursement for cognitive services, care coordination, referral activities and adherence to desired processes, such as the use of evidence-based clinical guidelines.

"We must realign payment models to reward physicians and other health care professionals for keeping populations healthy, rather than simply treating the sick," said Dr. Popik, a board-certified family physician. "Our model strongly emphasizes evidence-based care and the need to appropriately compensate those who practice it."

Under the DMAA model, accountable measures of success in population health should include clinical process and outcomes indicators; assessment of patient satisfaction, functional status and quality of life; economic and care utilization indicators; and effect on care disparities. DMAA is a leader in developing industry consensus guidelines on measuring clinical and financial outcomes in population-based care. Its two-volume Outcomes Guidelines Report has been widely adopted as a standard for assessing population health improvement program outcomes.

Key elements of the DMAA Population Health Improvement Model include:

• Population identification strategies and processes;
• Comprehensive needs assessments that assess physical, psychological, economic, and environmental needs;
• Proactive health promotion programs that increase awareness of the health risks associated with certain personal behaviors and lifestyles;
• Patient-centric health management goals and education which may include primary prevention, behavior modification programs, and support for concordance between the patient and the primary care provider;
• Self-management interventions aimed at influencing the targeted population to make behavioral changes;
• Routine reporting and feedback loops which may include communications with patient, physicians, health plan and ancillary providers;
• Evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall population health.

The principles also list numerous other model components, including recognition of cultural sensitivities; assistance to family, friends and other unpaid caregivers; and physician support for data collection and analysis, among others.

"The convergence of these roles, resources and capabilities in the population health improvement model ensures higher levels of quality and satisfaction with care delivery," DMAA says in the document released today. "Further, coordination and integration are important tools to address health care workforce shortages, individual access to coverage and care, and affordability of care."

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About DMAA: The Care Continuum Alliance
DMAA: The Care Continuum Alliance convenes all stakeholders providing services along the care continuum toward the goal of population health improvement. These care continuum services include strategies such as health and wellness promotion, disease management and care coordination. DMAA: The Care Continuum Alliance promotes the role of population health improvement in raising the quality of care, improving health outcomes and reducing preventable health care costs for people with chronic conditions and those at risk for developing chronic conditions. DMAA: The Care Continuum Alliance represents more than 200 corporate and individual stakeholders, including health plans, disease management organizations, health information technology innovators, employers, physicians, nurses and other health care professionals and researchers and academicians.