The document discusses achieving stakeholder engagement in population health management. It states that to improve care in a value-based market, health systems must become competent in PHM but it can be complicated by organizational barriers. It argues that to succeed, health systems need multidisciplinary support across the organization and that earning stakeholder backing relies on real-time, actionable data and analytics to measure effectiveness of improvements.

1. Achieving Stakeholder Engagement:
A Population Health Management Imperative
HEALTH CATALYST EDITORS

2. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Susan Seidensticker, BSIE, MSHAI,
CPHQ, CSSBB, PMP
Director, Waiver Quality Operations,
The University of Texas Medical Branch
This report is based on a 2019 Healthcare Analytics Summit presentation
given by Susan Seidensticker, BSIE, MSHAI, CPHQ, CSSBB, PMP, Director,
Waiver Quality Operations, The University of Texas Medical Branch, and
Andrew T. Herndon, MHA, CSSGB, Senior Business Manager, Office of the
President, The University of Texas Medical Branch, titled, “Serving the
Traditionally Underserved with Population Health Improvements.”
Achieving Stakeholder Engagement
Andrew T. Herndon, MHA, CSSGB
Senior Business Manager, Office of the President,
The University of Texas Medical Branch

3. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Achieving Stakeholder Engagement
To improve care in a value-based
market, health systems must become
competent in population health
management (PHM).
PHM, however, can be complicated
with organizational barriers including
information silos and limited resources.

4. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Achieving Stakeholder Engagement
To succeed, health systems need
multidisciplinary and cross-functional
stakeholder support that ensures
standard PHM work occurs across the
organization.
Earning this backing relies on real-time,
actionable data and analytics to
measure the effectiveness of
population health improvements.

5. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Achieving Stakeholder Engagement
An analytics-driven PHM program that engages the stakeholders
achieves the following:
Meets the unique
analytics and
reporting needs of
the organization.
Enables users to
measure, and
therefore manage,
PHM outcomes.
Provides the real-
time analytics
VBC requires.
Includes as many
stakeholders as
possible at the
beginning of the
journey.

6. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
PHM comprises strategies that guide
transformation across the continuum of
care to help organizations achieve
sustainable outcomes improvement—
versus focusing improvement resources
on limited populations and acute care.
Population health covers the full
spectrum of individual and population
health, making PHM strategies key to
ensuring improvement initiatives
comprehensively impact healthcare
delivery across organizations.
Why Population Health Management Is a
Must-Have Competency

7. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
How urgent is the need for PHM among U.S. health systems? By the
statistics, PHM is a healthcare imperative, as the nation’s rates of serious
medical conditions and associated costs are substantial:
Why Population Health Management Is a
Must-Have Competency
Six in ten adults in the U.S. have a chronic disease. Chronic diseases are the
leading drivers of the nation’s $3.5 trillion in annual healthcare costs.
4 percent of U.S. women and men will be diagnosed with cancer during their lifetime.
One in three American adults has high blood pressure, which costs $46 billion in
health services, medications, and missed workdays.
3 million Americans have diabetes—the nation’s seventh leading cause of death.

8. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
By guiding transformation across the
continuum of care, PHM strategies help
health systems manage concerns they
know their populations are at risk for (e.g.,
addressing the above conditions proactively
and reducing reliance on acute care).
Why Population Health Management Is a
Must-Have Competency

9. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Under PHM’s value-based model (e.g., at-risk
contracting and pay-for-performance arrangements),
organizations receive enhanced financial incentives
for delivering preventive services and tracking
patients across the care continuum.
Why Population Health Management Is a
Must-Have Competency

10. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
To manage these patients and succeed in PHM, organizations must rely on a
new set of data-driven, team-based skills.
To address the following broad scope of common population health
challenges, organizations must have systemwide stakeholder engagement:
Achieving provider engagement.
Measuring provider attribution.
Accurately identifying the numerator and denominator for each measure.
Making time to improve population health.
Capturing and managing the breadth of population health data and turn
it into actionable insights.
Achieving data-driven prioritization to select improvement opportunities
(must be current data to be actionable).
The Scope of PHM Challenges Calls for
Stakeholder Engagement

11. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
In certain states (including California, Texas,
Massachusetts, New York, and others), the
Delivery System Reform Incentive Payment
(DSRIP) program offers performance-based
incentives for improving care delivery to
Medicaid and other uninsured (underserved)
individuals.
Under DSRIP, states have millions of dollar
available for reinvestment annually, most of
which are tied to clinical outcomes.
DSRIP: Strengthening the Case for
Stakeholder Engagement

12. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
DSRIP goals tied to PHM include reducing the
total medical spend, improving patient
outcomes, and establishing a direct link
between provider performance and payment.
In Texas, for example, DSRIP ties payments to
performance in 30 measures tied to 32 rates for
traditionally underserved populations.
DSRIP gives health systems in Texas the
opportunity to earn millions of dollars in
incentives, which can drive stakeholder interest
in improving care for underserved populations—
especially when organizational objectives align,
and real-time data measures improvement.
DSRIP: Strengthening the Case for
Stakeholder Engagement

13. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Improvement teams can earn stakeholder
engagement in PHM programs, such as DSRIP,
by choosing measures that align with strategic
objectives (e.g., reducing emergency
department visits).
In Texas, for example, the University of Texas
Medical Branch (UTMB) picked primary care
measures for DSRIP and identified opportunities
for improvement to earn incentives while also
supporting organizational goals.
Aligning End-User Requirements with
Organizational Objectives

14. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Achieving PHM, and DSRIP incentives, requires
health systems to select strategic improvement
opportunities to maximize quality care and revenue:
Aligning End-User Requirements with
Organizational Objectives
Use custom reports developed by internal the clinical data
management team to select quality outcome measures
(“bundles”) that best align with organizational clinical strategy
(e.g., diabetes, heart disease, adult primary care, cancer
screening, and pediatric primary care)
Establish a broad
portfolio of team-
based efforts
across multiple
care settings.
Evaluate which
measures may be
beyond the
organization’s
current scope.
Leverage as
close to real-time
data as possible
(versus monthly
or quarterly
reports) to
achieve targets.

15. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
From securing stakeholder engagement to achieving
PHM goal, organizations must leverage real-time
data and analytics.
VBC is the new norm, and it requires real-time
analytics to measure performance and measures
as needed to succeed in PHM.
An advanced analytics tool for PHM must be
capable of compound measure stratification and
proactive (versus reactive) patient outreach.
It must also trend data over time to gauge
intervention effectiveness, show historical
context (e.g., whether trending up or down),
support attribution models and refresh daily.
Dynamic Reporting Leverages Real-Time
Data and Analytics

16. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Example capabilities of an advanced PHM
application include: filtering by disease,
location, department, and provider;
displaying composite scores and individual
measure scores; and graphing individual
measure performance over time.
This insight helps organizations improve
clinical processes by improving pre-visit
planning and proactive patient outreach;
implementing standardize clinic workflows;
and sharing ongoing, timely feedback with
clinics and providers.
Dynamic Reporting Leverages Real-Time
Data and Analytics

17. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
With the breadth and depth of PHM challenges
comprising the continuum of care from frontline
clinician engagement to real-time actionable
data, health systems must have organization-
wide stakeholder engagement to impact
population-based improvement.
Data Earns Stakeholder Engagement in the
PHM Journey

18. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Organizations in DSRIP states may more clearly
illustrate the challenges and opportunities in
PHM, but any health system stands to benefit
from a real-time data and analytics approach to
stakeholder engagement.
Data Earns Stakeholder Engagement in the
PHM Journey

19. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

20. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
More about this topic
Link to original article for a more in-depth discussion.
Achieving Stakeholder Engagement: A Population Health Management Imperative
Succeeding in Population Health Management: Why the Right Tools Matter
Amy Flaster, MD, MBA, SVP, Population Health Management and Care Management
Eric Just, Senior Vice President and General Manager, Product Development
Introducing the Health Catalyst Population Health Foundations Solution: A Data- and Analytics-first
Approach to PHM - Health Catalyst Editors
Pairing HIE Data with an Analytics Platform: Four Key Improvement Categories
Adam Bell, Director of Clinical Advisory and Provider Outreach Services; Carol Owen, SVP, Interoperability
Dan Soule, Vice President Product Management; Eric Crawford, Head of Product - Interoperability, Analytics & Big Data
Social Determinants of Health: Tools to Leverage Today’s Data Imperative
Health Catalyst Editors
Machine Learning and Feature Selection for Population Health
Health Catalyst Success Story

21. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
Susan Seidensticker has over 20 years of experience in healthcare performance improvement. In her
current role as Director, Waiver Quality Operations at UTMB Health, she serves as the program
manager for the portfolio of outcome measures that the organization is accountable for under the
Texas 1115 Waiver; these 30 measures represent 32 rates covering Adult and Pediatric Primary Care.
She is heavily involved in the regulatory and compliance components, as well as the organizational
efforts to develop and deploy interventions to work on improving these outcomes. Susan holds a
Bachelor of Science in Industrial Engineering from Purdue University, and a Masters of Science in
Health Administration Informatics from the University of Maryland University College.
She holds active certifications from the National Association of Healthcare Quality (Certified Professional of
Healthcare Quality), the American Society of Quality (Six Sigma Black Belt), and the Project Management Institute
(Project Management Professional), and has been published in the American Journal of Medicine.
Susan Seidensticker, BSIE, MSHAI, CPHQ, CSSBB, PMP

22. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
Andrew Herndon is a Senior Business Manager for The University of Texas Medical Branch (UTMB)
at Galveston, Texas. With work experience in both research and project management, Andrew’s
career has taken him to the United States Department of Agriculture and now UTMB. With a strong
focus on project management and efficiency, he hopes to better UTMB and Regional Healthcare
Partnership (RHP) 2 through meaningful interventions identified through innovative healthcare data
analysis. Andrew joined UTMB in 2014 and began working on Delivery System Reform Incentive
Payment (DSRIP) project management and regional anchor report consulting.
With exceptional results over the last five years, Andrew is Epic Certified and working towards real time data delivery
and intervention support at UTMB for population health initiatives. Andrew holds a BS in Biomedical Sciences from
Texas A&M University and his Masters of Health Administration from The Texas A&M School of Public Health. He is a
native Texan and resides in Hitchcock, Texas with his wife Nikki.
Andrew T. Herndon, MHA, CSSGB

23. © 2020 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
Health Catalyst is a mission-driven data warehousing, analytics and outcomes-improvement company
that helps healthcare organizations of all sizes improve clinical, financial, and operational outcomes
needed to improve population health and accountable care. Our proven enterprise data warehouse
(EDW) and analytics platform helps improve quality, add efficiency and lower costs in support of more
than 65 million patients for organizations ranging from the largest US health system to forward-thinking
physician practices.
Health Catalyst was recently named as the leader in the enterprise healthcare BI market in
improvement by KLAS, and has received numerous best-place-to work awards including Modern
Healthcare in 2013, 2014, and 2015, as well as other recognitions such as “Best Place to work for
Millenials, and a “Best Perks for Women.”