Clinical Population Management (CPM)
Implementing improvements at the population level
leads to improved care at the individual level.
A Step-by-Step Guide
OPTIMIZING PATIENT CARE the Clinical Population Management (CPM) way requires a desire to make changes – initiated by you at your discretion – that you believe will benefit your patients and your practice. If you’re interested enough to read this guide, chances are you’re the kind of physician who meets this requirement.
What it doesn’t require, however, is a huge time commitment. Our protocols were piloted and tested by busy physicians for busy physicians, so efficiency is a core value. Getting CPM launched in your practice takes less effort than you might expect, and then creates the capacity for all sorts of new efficiencies.
Our process is open access, meaning you have free, immediate online access to it here on this page. It includes three phases, each of which enables new capabilities within your practice that will lead to better care and improved workflows. Our goal with this guide is to provide clear and thorough instructions that enable you to implement CPM in your practice. A CME seminar is also in development that will walk participants through the entire process.
Create the capacity for all sorts of new efficiencies in your practice.
PHASE ONE | Building a Population Registry
CLINICAL POPULATION MANAGEMENT BEGINS with enrolling all your chronic disease patients into a population registry. Different disease populations are managed in separate modules within this registry. We suggest getting Phases One and Two up and running for one disease module at a time – while also beginning to explore Phase Three.
Some physicians designate a staff member to initiate and oversee this process. This tends to work tremendously well, especially when the designated "registry coordinator" is enthusiastic about pioneering this role. Regardless of who takes the lead, implementing a simple population registry is your starting point.
Phase One Capabilities
Once you’ve completed the steps in Phase One, congratulations! You’re now among the few chronic disease specialists in all of clinical practice with real-time data on how many patients you have with this disease, who these patients are, and who among them has high, moderate, low, and controlled disease. This means your practice team now has the framework in place to begin implementing CPM to improve your practice workflows and optimize patient care.
Now that you have a registry module populated and have begun documenting patient assessment data in it, you'll have the capacity to see assessment gaps that you previously had no way of seeing. Phase Two will enable you to address those gaps.
You'll find that the value of the registry data you’re collecting will further increase as you progress through Phases Two and Three, where you'll learn how to:
Click each step for detailed instructions:
Select a population registry.
Select a chronic disease and generate a list of all patients with that disease.
Load the patient list into your registry.
Select disease activity "signal measures."
Begin documenting patient data.
Patient Data Collection Sheet Template
Patient Data Collection Sheet Sample
PHASE TWO | Implementing On-time Assessment
Develop the capacity to address assessment and care gaps that previously you had no way of even seeing.
TRADITIONAL CHRONIC DISEASE CARE IS problematic in that it revolves around individual patient care at the time of an office visit. It’s a tenuous one-at-a-time approach that can start breaking down the first time a patient misses an appointment. In many cases, such patients will simply fall off the practice’s radar until (or unless) you chase them down or they take the initiative to schedule another visit. In addition, most clinicians don't have the visit slots necessary to see all their patients as frequently as intended, so appointment intervals get longer and longer as the number of patients increases over time.
That’s why despite best intentions, most chronic disease specialists have a significant percentage of patients who are overdue for a disease activity assessment. This is not an indictment of the profession, but rather a simple statement of fact that has emerged from current population registry data. The vast majority of chronic care specialists using CPM initially found care gaps that far exceeded their estimates – often for reasons beyond their control. CPM identifies the gaps and enables practice improvements designed to assure on-time assessments across the patient population. This in turn leads to better care and outcomes.
Phase Two Capabilities
While the activities of Phase One reveal care gaps, Phase Two provides a pathway for closing them. You now have an increasingly accurate data set that enables you to systematically work on increasing the number of patients with on-time disease activity assessments, and you can track your progress toward this goal. You can't provide on-time treatment unless you're providing on-time assessment.
Phase Two is a necessary foundation for Phase Three, in which you'll learn options for addressing the pervasive shortage of physician visit slots and other workflow challenges that impede on-time assessment, practice efficiency, and care outcomes.
PHASE THREE | Improving Workflows and Care Outcomes
Open up a world of opportunity for enhancing workflows and improving outcomes.
THIS FINAL PHASE IS ABOUT USING your new CPM capabilities to take patient care and outcomes to a whole new level. It's a menu of emerging options physicians are exploring to this end, and if you've completed Phases One and Two you're now in a position to consider any of them. The list of options in this phase will expand as physicians continue to find new ways to use population management-based strategies to impact team care, workflows, and patient outcomes
One quick tip for getting started: Don't try to do too much too fast. Sudden, significant changes in practice workflow or patient protocols can be highly disruptive and difficult to implement. Instead, select one option (or even part of an option) that feels simple and doable, then move into it incrementally, making adjustments as as needed. Continue exploring additional options at a pace that works for the physician, practice team, and patients. Keep in mind that trial and error is an important part of customizing and optimizing your CPM.
Phase Three Capabilities
Using your real-time CPM data you can now stratify patients into cohorts based on disease activity levels and interval since last assessment. This is a critical capability because it allows you to appropriately differentiate patient care based on need, which opens up a world of new opportunities for enhancing practice workflows and improving patient outcomes. You can also factor in disease duration, prognosis, and current treatments, if you include this information in your population registry.
Using CPM to redesign your workflows and patient care protocols will enable you to:
These improvements are enabling physicians to manage larger patient populations, improve access for new and established patients, reduce their costs per patient managed, and improve patient satisfaction measures in the process. And because documentation is at the core of CPM, physicians who use it are also building datasets that prove the value of the chronic disease care they provide.