At the core of population health management — a higher level of communication

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The concept of “population health” has elicited plenty of discussion, but little action. 

Wide-sweeping conversations about the value of addressing disparate health outcomes among the diverse residents of our country continue. But substantial improvements continue to elude providers across the country. Real action on population health begins with a higher level of communication to connect groups of individuals to care and be proactive about meeting their health goals.

Since the term was coined around 15 years ago, health care leaders have considered population health the distribution of health outcomes, the factors creating those outcomes, and broad strategies for addressing those outcomes. Thought leaders have introduced sweeping strategies to move the needle on population health, from global payments that pay for the care of a population instead of the care provided in a particular visit, to efforts to collect and analyze data on social determinants of health. But in order for these strategies to be effective and substantially improve health outcomes, providers who are already struggling with time-consuming reporting requirements and increasingly crammed schedules must take ownership of population health goals. Supporting providers in this work requires innovation in the area of communication—between providers and the communities they serve, between providers and their individual patients, and between large and bulky systems that house valuable health data.

Connecting the community to care
Providers are looking for actionable changes they can make to move the needle on population health goals and find success in value-based payment arrangements. They need better, more innovative tools to reach their communities. Payers are sending primary care providers and health systems massive attribution lists, requiring those providers to reach all individuals on that list and schedule new patient appointments with those who have yet to visit their clinic. Speciality practices are tackling equally daunting lists of referred patients, and all providers are grappling with understanding of each individual patient’s particular care journey so that they can better coordinate care with other providers.

Addressing health outcomes
To add to these outreach challenges, as payment is being tied increasingly to health outcomes, providers are looking for additional ways to support patients in meeting their care goals without adding to their already overwhelming workload. They are grappling with low levels of health literacy and need effective strategies to ensure their patients understand care plans. They want to improve medication and care plan adherence with timely and informative reminders. They also want to make sure that any new symptoms, questions, or concerns a patient has can be easily communicated back to the provider, who can adjust the patient’s prescription or treatment plan accordingly. A recent study called The Other 45 found that just 45 minutes of one-on-one time with a patient newly diagnosed with a chronic illness can significantly improve health outcomes by informing impactful self-management techniques. Provider-patient communication is critical—it can be the difference between successful treatment and years of debilitating health struggles.

Because so much of what affects health outcomes has little to do with the time a patient spends in a doctor’s office, patients must be able to drive and control their own health journey. They need open and convenient lines of communication with their providers to better understand their care plans and be able to ask key questions outside of the walls of the practice. Enabling the patient to take the reins in the provider-patient relationship is the most powerful strategy for improving health outcomes.Finally, systems must start communicating better. Interoperability of health data is essential for patients to be the owners of their own data, to be able to carry their health records with them from provider to provider. And providers have to be able to access data on their patients’ care journey, at least at a high level. They need to be able to estimate the risk their patients face of developing a chronic disease. They must also be able to predict costs and track key quality outcomes at the population level. This will allow them to generate more targeted strategies for improving the blood sugar levels of their high-risk diabetic population, for example, or preventing hospital admissions among their asthmatic population.

As the healthcare system pays closer attention to the value of care it’s delivering, innovation has to transform the way providers, patients and systems communicate with one another. Ultimately, on-the-ground action driven by this innovation can push the U.S. to meet its population health goals, and protect Americans’ health from the threat of the status quo.


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