How Cleveland Clinic Aims to Shape Population Health

After building a global reputation for providing complex, specialized care, the health system is building a care model that is designed to better meet the needs of the communities it serves.

Cleveland Clinic is launching an ambitious population health initiative designed to augment its world-class inpatient care, the organization's new chief of population health says.

"For Cleveland Clinic, we anticipate that as we manage population health well, we will create additional capacity for highly complex care. Some of our facilities are running close to capacity," says Adam Myers, MD, MHCM, FACHE.

Myers is also serving as director of Cleveland Clinic Community Care, a new population health approach at Cleveland Clinic. The approach features several elements of the organization, including primary care internal medicine, primary care pediatrics, family medicine, the organization's clinically integrated network of more than 6,000 physicians, Express Care, and the Center for Value-Based Care Research.

Prior to joining Cleveland Clinic, Myers served as the chief operating officer at Texas Health Physicians Group, a physician organization affiliated with Arlington-based Texas Health Resources.

HealthLeaders Media spoke recently with Myers. Following is a lightly edited transcript of that conversation.

HLM: What are some of the fundamental approaches to population health at Cleveland Clinic?

Myers: One is to help the healthcare system transition from volume to value.

Two is to focus on health, not simply on treatment of disease. For a long time, this has been a portion of what the Cleveland Clinic has done, but we can augment that quite a bit—not just for the folks we call patients but also for the communities we serve.

Three is creating additional access for patients and partnering with our community colleagues in addressing the social determinants of health.

Finally, we intend to work on enhancing the reliability of the primary care we deliver.

HLM: How does Cleveland Clinic plan to expand its population health efforts?

Myers: Initially, we are going to address the communities where we already live and work—northeast Ohio and other areas where we have physician practices in Florida. Ultimately, as we create a population health model, our hope is that it will propagate. Everyone is trying different approaches to population health and each community has its own opportunities and challenges. … We hope to come up with an approach that can be adopted elsewhere.

HLM: Describe a primary population health challenge at Cleveland Clinic and how the health system plans to address it.

Myers: Just like every other place, Cleveland Clinic faces finite resources. The changes in payment structures are underscoring the finite resources. However, we are determined and well-resourced to address this challenge.

We will be building teams around primary care providers—pharmacists, advanced practice providers, social workers, nutritional counselors, and behavioral medicine support to round out the team, so that the members of our teams can work closer to the top of their licenses.

HLM: Describe how your dual role as chief population health officer and director of Cleveland Community Care is designed to work.

Myers: I have the strategic and directional role of population health that will work with our primary care-focused efforts and our specialty institute partners. Then there's Cleveland Clinic Community Care, which is the operating nuts and bolts of primary care for the communities we serve.

HLM: What is Cleveland Clinic's approach to addressing social determinants of health?

Myers: Rather than assume what each community needs, Cleveland Clinic Community Care will partner with municipalities, community organizations, businesses, churches, existing healthcare teams in the communities, and other health systems to address the needs defined by both stakeholders and focused healthcare analytics. Our approach to social determinants will be tailored to communities.

At the Stephanie Tubbs Jones Family Health Center in the east side of Cleveland, we found that getting to appointments was a real struggle. Transportation was very difficult. We made a simple intervention that was a value-add intervention for the community. We provide 30 to 50 patient transportation opportunities per day.

The Cleveland Clinic does not intend to directly meet all of the community needs for social determinants of health. It's just not possible. We also do not intend to replace or displace the other support systems that are in our communities. We need to stand alongside what already is in place, find the remaining gaps, and work to either close gaps ourselves or help resource closure of gaps.