Five key staff roles for population health success

Population health initiatives are changing hiring practices and staff roles at primary care practices in fundamental ways.

As the efforts to transition a practice away from treating individuals to managing larger groups of patients that have similar comorbidities gets underway, hiring the right staff or providing staff augmentation through partnerships with outside healthcare stakeholders is essential to guiding the practice into a population health model of care.

In a population health value-based model, the goal is to hire the right expertise to carry out a mandate that aligns with the “Triple Aim” of enhancing the patient experience while reducing costs and improving patients’ health. To meet this goal, staff will be required to follow patients more closely as they look for gaps in care, manage, sort and analyze patient data, engage and educate patients better and connect with the wider community to extend patient care across a community of caregivers.

“When a primary care practice embarks on a population health initiative they’ll often be required to add new staff and redeploy existing staff to meet the needs of the patient population they are trying to serve,” said Tom Campanella, JD, associate professor of health economics and director of the Health Care MBA program at Baldwin Wallace University in Cleveland, Ohio.

Next: What positions are key?

Campanella said there are several key positions that every primary care office should have, or skills they should have access to if it wants to reap the rewards that come with participating in a population health initiative. These are:

IT/Data Manager: Now that physicians rely on patient information stored in their electronic health records (EHRs), a primary care office is going to need an IT/data manager on staff not only to maintain their systems, but also to help the practice access, sort and organize data that will present a clearer picture of the health of the populations they serve. Data will drive decisions. For example, once the data stratifies patients that have been hospitalized within the last 30 days, physicians can instruct their staff to take appropriate measures to following up with medication adherence for those patients.

Nurse Practitioner (NP) or Physician Assistant (PA): These roles provide an array of services such as meeting with patients to understand their medical issues, documenting patients’ vital signs and making preliminary assessments on  patients’ conditions before the physician enters the room. Providing these services allows physicians more time to assume a higher clinical manager leadership role. NPs and PAs also are tasked with improving patient engagement and education, and assist with processing claims with health insurers and managing referrals to specialists.

Specialized Skilled Clinician: If the practice has a significant amount of patients that have a chronic illness, it might be best to hire a clinician that specializes in a particular area of medicine. For example, if 70% of patients have diabetes, that practice should consider hiring a diabetic nurse that can follow up with examinations of the feet, eyes, obesity and A1C levels.

Next: Know your population

Social Workers: As social determinants of health play an increasingly critical role in evaluating a patient’s health and wellbeing, a social worker can play a critical role at a primary care practice, particularly those in rural areas or in inner cities where low income populations often have limited access to quality health care. One of their key roles is to connect with community agencies that help individuals with specific care needs. For example, if a practice has a group of patients with mental health problems, a social worker can arrange for patients to visit a community mental health facility to receive care and follow up treatment.

Because the success of patient outcomes is tied to incentive payments and failure translates to payment penalties under a population health initiative, Campanella told Medical Economics that it’s critical primary care practices know their patient population which will in turn dictate their staffing needs, what skills are required and how their staff will execute their tasks to make a population health initiative work.

“It’s not just about improving health outcomes, reducing costs and improving the experience of a group of patient, it’s also about making sure the practice has the staff that can make a profit while doing all those things,” Campanella said.