Addressing patient and member needs during the pandemic: a robust population health framework is key

As the COVID-19 pandemic turns the world on its head, integrated health care systems excel when they can rely on robust existing systems to manage and improve population health.  

An organization population health mindset means the following: knowing the population you serve to best meet their needs, hard-wiring how to best address gaps in care, and supporting appropriate utilization of the care provided.

By relying on this existing strong population health framework that emphasizes value-based care and actively identifies gaps in care, we can strengthen our own health systems and the vulnerable populations we serve—our most urgent priority during this crisis. 

Knowing Your Population: The Importance of Using Data Before a Crisis

Presbyterian Healthcare Services is an integrated system of hospitals, healthcare providers, and payers. By uniting key stakeholders in one system, we gain greater access and insight into key data—combining claims data from our payers, real-time data from our hospitals, and social determinants of health and behavioral health data from various sources. 

When pieces of data come together to create a complete picture of each patient or member, it becomes easier to identify those with rising risk as well as resolve gaps in care—both for the individual patient and for the entire population. 

Before the pandemic, our population health team partnered with clinical teams across Presbyterian on many efforts to improve care and reduce costs for patients, such as programs focused on reducing avoidable Emergency Department visits, improving diabetes management and reducing costs in post-acute settings.

Hard-wiring this approach, along with the use of data from across an integrated system, was key in providing proactive support during the COVID-19 pandemic to ensure that our most vulnerable patients and members were safe. 

Early on, as other parts of the U.S. were feeling the surge in the early days of the pandemic, New Mexico had not yet seen any virus cases. 

Using that extra time, our Analytics team was able to use data to identify more than 20,000 of the most vulnerable Presbyterian Health Plan members who were at-risk for adverse COVID-19 outcomes. Our health plan care managers then reached out to patients individually, and made sure patients received existing chronic condition medications at home—preventing the patient from needing to leave his or her home and risk COVID exposure. While this work started with the most vulnerable, outreach has continued to additional members to proactively identify their needs.

Caring for a Diverse Patient Population

New Mexico is a beautiful, diverse state with a large rural population. Our state is also challenged by a high rate of poverty, with 2017 numbers from the U.S. Census Bureau estimating that nearly one in five New Mexicans live below the federal poverty level. In addition, about two-thirds of the population relies on Medicaid or Medicare. 

From a healthcare perspective, this poses unique challenges when developing an effective population health approach. Our population may be more likely to face negative impacts from poor social determinants of health, which include homelessness, housing and/or food insecurity, lack of education, crime and lack of neighborhood safety, unemployment, or underemployment. 

We also know that the COVID-19 pandemic has further exacerbated disparities in care across the country and in New Mexico — disproportionately impacting patients based on race and ethnicity. 

Caring for diverse groups of people requires a strong population health strategy that enables the organization to know the population well enough, through available data, to identify and address gaps in care. 

Identifying Gaps in Care 

The World Economic Forum estimates that the global pandemic, and subsequent 20 percent drop in income from the recession it caused—will push 500 million people worldwide into poverty. Poverty, and other social determinants of health, can account for up to 80 percent of an individual’s health outcomes. 

A report from the Pew Research Center shows that communities of color are being disproportionately affected by the recent unemployment spike, with 49 percent of Hispanics specifically reporting that either they, or someone in their household, has been laid off or taken a pay cut as a result of the COVID-19 outbreak. Among all U.S. adults, that number is 33 percent. 

The economic crisis due to the pandemic has increased food insecurity, which has hit many New Mexicans, and Americans, hard.  

Using data, Presbyterian was able to identify which members had been diagnosed with COVID-19 and were also vulnerable due to income and other factors —and reach out to them with a two-week supply of meals for the patient and his or her family. 

Providing a reliable and healthy food supply helped ensure individuals stayed safe and reduced the stress of not knowing where their next meal is coming from.  Additionally, it allowed these members to stay in their home while recovering, avoiding further spread of the virus to other community members.

Adapting and adjusting virtual solutions 

Creating an adjustable strategy that can be adapted as situations continue to change is key to a thriving population health approach—even in the middle of a pandemic.

For Presbyterian, preventative care is critical in ensuring appropriate utilization and population management. 

When the pandemic hit, we realized that many of our most vulnerable populations would struggle to safely keep preventative care appointments. Like many systems, we shifted a significant amount of our care to telehealth during the pandemic, including about 80 percent of primary care visits. Using data, Presbyterian Medical Group was able to proactively reach out to patients to bridge gaps and engage vulnerable individuals during this shift to telehealth. Ensuring that these patients have the resources necessary to complete telemedicine visits was critical.

A remote monitoring program developed in collaboration between Presbyterian Health Plan and Presbyterian Healthcare at Home is another proactive innovation. The program focuses on select members diagnosed with COVID-19 who can safely recover at home with additional support, including remote monitoring of oxygen levels and temperature. The goal is to offer early interventions before health concerns become severe. Ideally, this approach can quickly recognize and treat symptoms before they worsen and help avoid hospitalizations. Our integrated system continues to look at ways to bring other types of virtual access into patient and member homes.

As healthcare continues to shift post-pandemic, finding similar realistic but out-of-the-box solutions for supporting our most vulnerable populations will become even more critical. As we leverage data to better identify gaps and support appropriate utilization, we’ll be better prepared to identify ways to stay ahead of the curve, minimize the impact of future crises on specific patient populations, and keep our communities healthy. 

Related Reading: Breaking Free: The Cost and Benefits Behind Breaking the Incarceration and Addiction Cycle of Those with Substance Use Disorder

Darcie Robran-Marquez, MD, MBA, CPE, is the Executive Medical Director and VP of Population Health at Presbyterian Healthcare Services. She completed her undergraduate work at New Mexico State University (Psychology and Microbiology); she remained in her native state for medical school and Family Medicine Residency at the University of New Mexico. Dr. Robran-Marquez later completed her MBA in Healthcare Administration and Management from Regis University, before joining Presbyterian. 

As the Medical Director of Primary Care and Urgent Care Services, Dr. Robran-Marquez was responsible for the management of 140 internal medicine, family medicine, and urgent care physicians, nurse practitioners, and physician assistants. She successfully designed and implemented a Level 3 NCQA accredited Patient Centered Medical Home in ten primary care clinics across the state. Dr. Robran-Marquez served as the VP of Medical Affairs and Chief Medical Officer of Molina Healthcare for nearly six years, before returning to her current role at Presbyterian.

This article is published through a partnership with Collective Medical

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