Towards Regional Population Health Management: A Prospective Analysis Using the Adjusted Clinical Groups Classification.

This research seeks to assess the potential of regionally integrated health management for specific sub-populations, including the incorporation of self-management initiatives. It will achieve this by conducting a thorough stratification analysis of hospital data, utilizing the Adjusted Clinical Groups (ACG) classification system. The approach involves a retrospective review of healthcare data spanning five years, which includes patient demographics, health outcomes, and healthcare utilization metrics. We intend to use the ACG method to classify the patient population into pertinent groups that mirror their health requirements and resource use. The insights obtained from this analysis will be used to create a localized adaptation of the Kaiser Permanente Pyramid Model of Care. This adaptation aims to identify the distribution of costs among patients treated in the Rivierenland Hospital. We anticipate that stratifying data with the ACG method will identify distinct multimorbid subgroups. These subgroups will have unique healthcare requirements. Early interventions and customized health management strategies, based on these insights, could enhance health outcomes and resource efficiency for high-risk patients. This analysis will serve as a foundation for constructive discussions with hospital management and clinical staff, fostering a deeper comprehension of the patients' burden of disease. It might also foster multidisciplinary collaboration opportunities between medical specialties as with regional healthcare partners such as general practitioners (GPs), mental health and other long-term care organizations. Moreover, we anticipate that self-care initiatives, supported by customized health information, will encourage increased patient engagement and strategies for enhancing lifestyle improvements. This strategy is expected to enable the personalization of advanced care planning based on individual needs profiles, thereby improving the management of complex and chronic conditions, and encouraging self-care practices. Our anticipated findings highlight the potential benefits of a data-informed approach to advancing healthcare outcomes and present opportunities for future investigations to refine and implement such integrated care models across the region.

Self, at Home, and Digital if Possible, Drivers to Population Health Management.

The Dutch healthcare system is known for its strong emphasis on primary care and a decentralized approach to healthcare delivery. This system will have to adapt in view of the ever-increasing demand and overburdened caregivers, because otherwise it will eventually be insufficient to offer patients adequate care at sustainable costs. The focus must shift from the volume and profitability of all parties involved to a collaborative model for achieving the best outcomes for patients. Rivierenland Hospital in Tiel is preparing for a shift from treating sick patients to promoting the general health and well-being of the population in the region. This "population health" approach aims to maintain the health of all citizens. This transformation to a value-based healthcare system, centered on the needs of patients, requires a complete overhaul of the current systems and its entrenched interests and practices. The regional healthcare transformation requires a digital transformation characterized by several IT implications, such as facilitating patient's access EHR data and sharing information at patient journey level to support the partners involved in the regional care and cure for patients. The hospital is planning to categorize its patients in order to establish an information database. This will help the hospital and its regional partners to identify opportunities for regional comprehensive care solutions as part of their transition plan.

The Tiel Shift Towards Person Centered Care.

The health system in the Netherlands is one of the best in the world and it is a challenge to keep this affordable and accessible for everyone. A shift from care to lifelong maintenance of health is highly needed, but the drivers of change are missing. Obviously, the involvement of citizens is essential, but to introduce the change the indispensable incentives must be identified. The believe in integrated network care is growing, but it requires a fresh view on the integration of prevention and care, the involvement of the "old players" to create a new governance model, the supporting IT and adequate funding arrangements. In the Tiel region the implementation of the INCA model for integrated care in the primary care setting might make the difference for this journey.

Person-Centered Care Coordination Next Steps in a Long Journey.

Citizens of the Netherlands receive excellent care, when they need it, insurance based funded according to the solidarity principle. Maintaining this system is a huge challenge, as we live longer and the demand for care is growing. With an increasing percentage of multi-morbidity in all age groups the need for integrated network organized care is growing at equal pace. Gradually the need to shift focus to prevention is increasingly understood, but a challenging business model is still lacking. The involvement of citizens in maintaining their health requires a focus on managing the social determinants of health. The concept of the holistic problem list and the overarching care plan provides a unique way to combine both health and disease management. Our vision is to bring control to the patient and promote coordination of all active problems across the health and social care network.

Continuity of Health, Citizen Empowerment as Key Driver.

Self-management for prevention and care will play a significant role in the transition to apply person-centered care. Interoperability requirements, an overarching care plan, integration of social determinants, and the focus on prevention are important ingredients in the vision on its implementation.

Transition Requirements from Problem List to an Overarching Care Plan for the Support of Person-Centered Care.

To keep healthcare effective, accessible and affordable to all we need a fundamental paradigm shift. Self-management for prevention and care with the help of healthcare professionals, having a shared view of the state of well-being, will play a significant role in this transition. The problem list is widely adopted as centerpiece of electronic health records and is although often patient oriented, but mostly limited to the institutional level. The requirements for this paradigm shift has been discussed in a series of workshops. Truly person-centered care requires to move towards a holistic problem list with an assessment and planning process resulting in an overarching care plan. The change process towards a real person-centered problem list, integrated in an overarching care plan, should be focused on the transition of health services delivery and requires a transition based on the "Quadruple Aim" principles.

A Short Factography About IMIA and EFMI.

International Medical Informatics Association (IMIA) and European Federation of Medical Informatics are scientific associations which represents Health/Medical informatics as scientific and profesional disciplines. Those associations have long tradition in spreading knowledge, experiences and strategies in organization, practical applications and education within Health, Medical and Biomedical informatics in approximately 60 countries the world. In this review we present basic facts about IMIA and EFMI.who celebrate this 50 years of their establishing as professional associations.

Patient centered integrated clinical resource management.

The impact of funding systems on the IT systems of providers has been enormous and have prevented the implementation of designs to focused on the health issue of patients. The paradigm shift the Dutch Ministry of Health has taken in funding health care has a remarkable impact on the orientation of IT systems design. Since 2007 the next step is taken: the application of the funding concept on chronic diseases using clinical standards as the norm. The focus on prevention involves the patient as an active partner in the care plan. The impact of the new dimension in funding has initiated a process directed to the development of systems to support collaborative working and an active involvement of the patient and its informal carers. This national approach will be presented to assess its international potential, as all countries face the long term care crisis lacking resources to meet the health needs of the population.

Health care process and workflow in continuity of care.

Basically, the workshop aims to raise and collect input to Part 2 ("Health care process and workflow"), currently under development, of the European standard EN 13940 "Health informatics - System of concepts to support continuity of care", the general objective of which is to enable communication at the semantic level between information systems in health care in the perspective of continuity of care. Its scope encompasses identifying the various processes and process objects involved, taking into consideration resource management aspects, responsibilities of health care providers, and means for patients' participation. While the process description and concept system model is meant as a tool for the development of information systems, it may also be used for enterprise analysis and form the basis for organizational decisions and more widely organizational developments that are not inherently tied to the use of ICT.