How COVID-19 is changing hospitals' population health strategies

The COVID-19 pandemic has challenged hospitals to develop new approaches to managing patient populations. To effectively manage population health, organizations must balance keeping people in their communities healthy and caring for patients infected with the illness, all amid worsening care disparities and social determinants of health. 

Here, hospital and health system leaders share with Becker's Hospital Review how they maintain that balance and how their approach has changed.

Editor's note: Responses were lightly edited for length and clarity. 

Don Calcagno, senior vice president, population health and managed care at Advocate Aurora Health (Milwaukee and Downers Grove, Ill.)

 At Advocate Aurora Health, we have been able to use, or in some cases adapt, certain population health programs to serve COVID-19 patients. One example is using our population health team to monitor patients discharged from our hospitals or emergency rooms. Not only has the program shown great statistical results; more importantly, we continue to receive grateful comments from patients who had felt isolated and afraid prior to this outreach. We could not be more proud of our teams and this important work.  

More broadly, the pandemic has highlighted the need to accelerate some of the population health work we already had started. For example, having physicians on an integrated electronic medical record has greatly helped us collect data and create patient registries over these last few months, confirming the value in bringing even more of our clinicians onto a common platform. 

Like other providers during this pandemic, we have seen significant reductions in certain types of utilization, including skilled nursing facility and emergency room visits, and increases in other forms like virtual health. We must now ask ourselves: In cases where not using the emergency room was clinically the right decision, how do we hardwire that decision beyond the pandemic so we can provide safe, high quality, efficient care in the right care setting?

With more patients and physicians now more comfortable with virtual health, how do we maintain and expand the use of these services moving forward? Addressing these types of questions will help inform our future population health strategy.

Lastly, we have always believed bearing financial risk is the best way to advance key goals of providing the safest care and achieving the best health outcomes possible. These models made it easier to pivot our resources to where they could serve our patients best.

Rebecca Cunningham, MD, associate CMO of Brigham and Women's Physicians Organization (Boston)


Daiva Braunfelds, executive director, population health management and physician engagement, Brigham and Women's Physicians Organization 

At Brigham Health, we have adapted our population health strategy to focus on proactive outreach to vulnerable populations most at risk for coronavirus infection or complications. We are identifying patients with medical conditions or of older age that place them at risk, as well as patients who reside in hot spot communities with high infection rates. We are leveraging our existing population health teams, including nurses, community health workers, community resource specialists and others to reach out by phone to provide education, assist with healthcare proxy identification, and address social determinants of health.  

We are also using new modes of connecting with patients, including text-based outreach and virtual visits for patients identified at risk for care that may have been delayed, or whose primary care physician is concerned about their well-being. We have established pop-up sites for COVID-19 testing, screening for social determinants of health needs, and provision of resources, including masks, hand sanitizer, and home food delivery for patients. We've been better able to help reach patients in hard-hit communities by removing barriers to care and providing the resources that people need to stay safe. 

The response from patients has been very positive, as many have been reluctant to reach out or seek care, and they appreciate the care team coming to them. We are adapting our approach as we move forward and anticipate the reopening of ambulatory sites and using our learnings from the crisis to drive positive changes in our population health approach to needs identification, outreach, access and follow-up with patients.

Cynthia Litt Deculus, vice president of population health management for Cedars-Sinai Health System (Los Angeles)

We are working to ensure that our patients do not delay getting necessary in-person care, such as cancer screenings, diabetic retinal exams and childhood vaccinations. It's very important to make patients feel safe coming into the office for necessary visits and to use effective alternatives to close gaps wherever possible, such as at-home FIT testing for colon cancer screening. 

Much of primary care is handled virtually now — which has proved very popular — and we're supporting our primary care providers with tools and workflows that  help them make this process run smoothly. 

Complex care management is going very well because the staff is 100 percent focused on their highest risk patients, and patients are more accessible and willing to engage over the telephone than ever before. Our pharmacists and dieticians are having meaningful phone consultations with diabetics and patients with high blood pressure, and we're calling our socially isolated seniors frequently and engaging them in a free online exercise program. We find that our high-risk patients are taking better care of themselves because of their fear of the virus.

Overall, patients are finding that their physicians have greater accessibility through virtual options such as secure messaging, and we're getting wonderful feedback about how easy it is to stay in close touch.

Carrie Harris-Muller, senior vice president of population health for OhioHealth (Columbus) 

Pre-COVID, our population health goals and strategies were designed around challenging the status quo to improve health in our communities. We were making progress, but the pace of change and acceptance has definitely accelerated with the pandemic. 

In just a few days, COVID upended the episodic and acute care-focused nature of our country's healthcare system. While that has been incredibly challenging, in a sense, the pandemic has actually fueled our strategy. There's an intense focus on new collaborations and care setting options in response to COVID. The upside is that key components of our roadmap have been fast-tracked. 

We were able to put the pedal to the floor and deliver new telehealth access points, not just for primary care, but for patients with chronic conditions and behavioral health needs. That resulted in almost 150,000 video and phone visits since the end of March. 

OhioHealth at Home stood up Advanced Home Services, a program that allows patients who would traditionally be admitted for observation or inpatient care to be monitored at home. That offers safety and peace of mind for patients and relieves the demand on hospital beds.

COVID has also helped us accelerate our analytics work, which is a key component to having a truly holistic view of populations. 

Population health has been a priority for OhioHealth, but the pandemic put it front and center in a whole new way. In these times of crisis, people got a front row seat to the power of a population health mindset fueled by a sound business strategy. It's about the right care, in the right place for the right people. Our back-to-business plans are maintaining that focus as we work to bring volumes back to pre-COVID days.

Susan Hawkins, senior vice president for population health for Henry Ford Health System (Detroit)

Our overall theme for changes needed in our population health management approaches mirrors changes needed in other areas of the health system:  We need to reengage with our customers and each other in both new and different ways in the post-COVID "new normal."  Examples include:

  • New ways to address social determinants of health. In our markets, food insecurity and safe housing needs rose to the top of the list in terms of volume and urgency.
  • New approaches to case management and chronic condition management across the continuum.  Ongoing changes include converting many in-person care-planning visits to telehealth interactions, focusing on transitions of care needs follow emergency visits or hospitalizations, and reprioritizing post-acute care in the home over skilled nursing facilities.
  • Rapid expansion of new services to allow safe care at home and to free up capacity in hospitals and emergency departments during future pandemic surges.  Programs such as our Mobile Integrated Health paramedicine and hospital-at-home services that incorporate virtual physician visits and traditional home healthcare will allow us to deliver on our population health strategy as a health system.

Jason Mitchell, MD, CMO of Presbyterian Healthcare Services (Albuquerque, N.M.)

Population health has never been more important than during this pandemic. We have experienced the positive impact of population across our health plan, medical group and hospitals. Through our integrated analytics we:

  • Identified more than 20,000 health plan members at risk of adverse COVID-19 outcomes and did outbound calls to ensure they had mail order for all prescriptions and helped them get necessary refills. This helped prevent members form going into a healthcare setting unnecessarily, provided information on how to protect themselves from COVID-19 and helped connect them to social services. 
  • Redesigned our medical group's visit templates and processes based off principles of population health.  Using integrated analytics, we identified patients at higher risk and reached out to schedule telemedicine visits to ensure they had all their needs met and ensured medications were refilled. We quickly converted 80 percent of our visits from costly in-person visits to virtual visits and simultaneously saw a reduction in claims cost and improvements in patient satisfaction.
  • Engaged and supported our physicians and advanced practice clinicians with data and process to develop a variety of new ways to preemptively improve care of diabetes management, COPD and a variety of other conditions.  We are able to detect and do outreach to patients before they have problems and are able to identify when high cost treatments that are not leading to clinical improvements and replace them with affordable solutions that are delivering better results.

As the pandemic evolves, we anticipate even more work continuing to be driven by population health approaches and solutions.

Adam L. Myers, MD, chief of population health at Cleveland Clinic
Director, Cleveland Clinic Community Care

Our population health strategy pre COVID-19 consisted of many components, each of which has accelerated in pace and heightened in importance.

As is the case with many health systems, virtual care has moved to the forefront and is now a crucial component of care delivery. Our ability to scale this quickly has been critical to our success in meeting the needs of the populations we serve. In addition to it becoming a key care modality for all of our caregivers, we also have expanded our "virtualist" team that works collaboratively with our nurse-on-call group, our remote-monitoring program, our house calls group, our SNF-at-home program, our chronic disease management team and our urgent paramedic dispatch program. Linking these innovative efforts into a comprehensive safety net for those most vulnerable has provided a proof case for the approach already in process.

COVID-19 has tragically underscored what we previously knew to be true. Years of economic, political, educational, and health access disparities have once again placed African-American and other minority communities at disproportionate risk for COVID-19 and all it entails. We are working collaboratively with other community partners to both address the urgent needs and move forward in what will be a yearslong effort to serve as an anchor institution determined to strengthen our communities. As we do so, we are wise to be attentive to how our shift to virtual care can actually worsen access to care for those without reliable broad-band access.

Finally, enhancing the value of the care we provide has only become more important, secondary to growing demand and increasingly scarce resources. As a result, we are leaning in on our transition to value-based payment models. 

The populations we serve need us now more than ever, and we are answering that call.

Chris Wilson, vice president, system integration and innovation,  University of Kansas Health System (Kansas City, Kan.) 

We always prioritize preventive care and closing gaps in care for our patients. The impact of COVID-19 on individuals with chronic conditions has only emphasized that we maintain the health of our patients in a proactive manner.  

We are especially aware of the impact that social determinants of health have on our patients. COVID-19 may have exacerbated that impact. Critical aspects, such as access to care, transportation, and warm hand-offs to social services, are of increased importance for our practices during these times. Our rapid investment in and deployment of telehealth has created multiple additional channels for patients to access care to mitigate the challenges social determinates may present.  We completed our two-year telehealth implementation plan in two weeks and surpassed 46,000 telehealth visits in March/April/May. 

Our general approach has also addressed population health needs. At The University of Kansas Health System, we have focused on two paths: creating the capacity to care for COVID-19 patients while at the same time keeping our communities healthy. To help keep our communities safe, we expanded our internal lab into a testing facility for our region in less than four weeks. To date, out of our 10,000 COVID-19 tests, we have run more than 3,400 COVID-19 tests for eight counties and cities that make up the majority of the Kansas City region, as well as for our Federally Qualified Health Centers partner. 

The public is also hungry for trusted information to make good choices, especially now. To help our community make informed decisions, we created a daily media update for reporters to help them better understand the pandemic and share health safety guidelines with the public.  The community rapidly embraced the expert information, and the daily audience has crossed state lines and continents.  Topics range from basics like how to wear a mask, social distance and stop the virus spread to more weighty subjects such as contact tracing, modeling and mental health. 

As the region's only academic health system, we have always known our role is larger than providing the most advanced care in the region. During this pandemic, we have made our resources as available as possible to our community knowing we will rise together stronger, and we look forward to a brighter tomorrow.


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