Improving Population Health in the Digital Era

Many health systems are investing in population health management strategies, which help them understand target populations while identifying risks and unmet needs. Digital tools such as Aerial by Medecision can provide the data-based insights that empower clinicians, physicians, consumers and their caregivers toward continuous engagement and improved care management.

By Medecision

Adaptation is crucial in the healthcare industry, where providers are constantly taking in new information—and modifying their approach accordingly—to achieve the best possible outcomes. At the same time, they must be proactive in anticipating future problems and needs. The industry’s ongoing shift from a fee-for-service reimbursement model to a value-based care (VBC) model reinforces the necessity of both flexibility and foresight.

As health systems sharpen their focus on maintaining patients’ health rather than just addressing the disease or ailment, many are investing in population health management strategies, which help them understand target populations while identifying risks and unmet needs. An essential part of this process is the ability to harness actionable information about patients.

Population Health Management

The American Hospital Association (AHA) Center for Health Innovation defines population health management as “the process of improving clinical health outcomes of a defined group of individuals through improved care coordination and patient engagement supported by appropriate financial and care models.”

Patients’ unmet needs often are related to social determinants of health (SDOH): factors such as housing, transportation, access to healthy food, employment and education level. Understanding a patient’s condition in the context of these factors and working to address them can lead to better health outcomes—not only for that patient but potentially also for others who live in the same ZIP code, work similar jobs, and share lifestyles and challenges.

Recognition of the interconnectedness of people’s environment and their health dovetails with the holistic approach that underpins VBC models. Looking at the whole person helps to put the disease or ailment in context and informs that person’s treatment. Does he or she have access to the food, medicine, resources and support needed to provide the best possible care not just now but throughout life? Can preventive measures taken now reduce the likelihood of future problems—and unnecessary expenses—for the benefit of patients, providers and payers?

We have previously written about the pandemic’s toll on the fee-for-service model: providers’ difficulties in getting paid for their services; the high cost of caring for COVID-19 patients; declining volumes due to increased employment; and a rising Medicaid business, which is often the highest-cost care to provide. These challenges underline the importance of moving to a reimbursement model based on value rather than volume, and of taking the long view of health maintenance.

Digital Tools and Data

Over the past year and a half, certain tools and approaches have shown themselves to be indispensable, not just for confronting a pandemic but also for the ongoing success of healthcare organizations in fulfilling their mission.

Virtual health, for example, has proved to be both medically and cost effective in providing the needed care while making the most of limited resources. Community-based care, which must be built on a foundation of trust, helps identify the populations that are most in need and at risk, pinpoint the gaps in resources and determine how to fill them.

Such complex problems require complex solutions that integrate empathetic, high-touch care with tools that guide and support that care. That means investing significantly in human resources as well as in technology, analytics and care management. It also means payers and providers must coordinate their efforts to improve care delivery and eliminate duplication of efforts.

The extensive use of clinical data helps identify at-risk members of health plans and intervene appropriately, depending on the risk: heart disease, diabetes, COPD or another chronic condition. Targeted prevention and wellness programs can help keep members healthy and avoid costly visits to the doctor or emergency room.

Health plans can encourage members to visit their doctor if they haven’t done so in a while, and send them information on why a particular vaccine is important. By steering members in the right direction, plans can help keep them in good health and potentially out of the hospital. This can ensure better outcomes—and keep costs down.

Data and analytics enable providers to better understand the population and drive member engagement. Using this more holistic approach, multidisciplinary teams look not only at medical issues but also behavioral and emotional ones.

Understanding outcomes and identifying patterns of causality are necessary to effectively manage the health of patients impacted by complex conditions, behavioral health issues or SDOH. So is the ability to measure the success of your activities in addition to the outcomes.

Wherever your healthcare organization might be in the shift to value-based care and population health management, the effective use of data and digital tools will become increasingly important in this journey.