- Even for the most enthusiastic and forward-thinking healthcare organization, developing robust and impactful population health management programs can be a difficult proposition.
Budget constraints, a lack of commitment from executive leaders, concerns about new workflows, EHR woes or interoperability issues, and resistance from clinicians worried about time management or extra tasks can quickly derail any practice transformation effort.
Many of these problems stem from poor planning, inadequate internal communication, and the incorrect assumption that population health management must be a massive, big-bang, all-or-nothing affair.
In fact, it probably shouldn’t be. Providers that take a measured and incremental approach to population health management, care coordination, health IT upgrades, and big data analytics projects may even have more success than those that decide to jump into a complete overhaul of their entire organization overnight.
That’s because it takes time, practice, and some convincing data points to enact lasting change without overwhelming or alienating clinicians who may feel fed up with the constant stream of regulations, reporting, and reforms taking their attention away from patient care.
An easy way to overcome the reluctance of busy providers – and financial officers with an eye on the bottom line – is to start small with a few high-impact, low-effort test cases targeting specific patient populations. Not only will that strategy keep expenses under control, but it will likely also build confidence and engagement for staff and patients.
“For a lot of people, creating a population health management infrastructure seems intimidating,” said Peter McClennen, formally head of Allscripts’ population health activities and now CEO of Best Doctors. “They think they have to buy everything all at once, but that’s not necessarily the most efficient strategy. You can start anywhere, so it doesn’t have to be quite so expensive.”
Helping patients improve their chronic disease management skills are excellent starting points for an organization trying to get its feet wet with population health. With little additional technological investment and only a few workflow adjustments, providers may be able to improve outcomes, reduce costs, and raise patient satisfaction.
Here are five potential population health management entry points for providers looking for cost-effective ways to prove that positive change can come from the smallest actions.
Cultivating engagement and education for diabetes patients
Diabetes is of one of the most costly, common, and underdiagnosed chronic diseases in the nation. Despite sustained attention from top organizations like the CDC, AMA, and CMS, millions of patients still suffer from avoidable complications brought on by low levels of health literacy, inadequate follow-up, and astronomical rates of medication non-adherence.
Text messages, patient portal interactions, and mHealth communications may be a simple and low-cost way to remind patients that they are due for follow-up appointments, prompt better dietary and lifestyle choices, and keep diabetics on track with their blood sugar testing protocols.
One study from the Journal of Medical Internet Research found that automated motivational messages helped diabetics improve their HbA1c scores by 0.53 percent, which could significantly reduce the likelihood of developing long-term complications.
“This type of intervention could address non-adherence to lifestyle recommendations by providing frequent reminders, motivational support and prompts to action, as well as timely access and feedback to relevant health information, while making patient-provider communication much easier,” the study said.
The messages don’t even have to be interactive. One-way reminders that require little action from providers were just as effective as bidirectional communications.
mHealth apps and messages may also provide education to patients who are unsure about how to cope with their diagnosis, and are in high demand among patients.
A 2015 survey found that 65 percent of diabetic patients would like their providers to offer mHealth tools to help them develop and adhere to a chronic disease management plan. The survey also revealed that patients lack basic knowledge about diabetes, including the fact that Type 2 diabetes is generally preventable or may be reversible with better lifestyle choices.
Taking a few extra moments in the consult room to asses a patient’s diabetes literacy level and provide some basic facts with a printed FAQ sheet may be all that is required to help a new diabetic understand and address her condition.
Improving screening rates and integration for mental healthcare
Mental healthcare is another area in which taking some time to ask a few questions could produce significant results. Many providers already employ basic depression screening questionnaires, and an increasing number of organizations are offering telehealth or mHealth services to deliver care to patients with mental and behavioral healthcare needs.
But not every organization is fully aware of the impact that an undiagnosed mental health condition may have on chronic disease management and overall wellness.
Depression, for example, can seriously interfere with self-management activities. A 2014 study of diabetic patients found that providing support for living with depression produced a 1 percent drop in HbA1c levels – twice that generated by the mHealth messages detailed above.
Unrecognized depression and social isolation may also increase the risk of premature death in hospitalized seniors by 14 percent. For members of the military and veterans, the risk of dying by suicide stemming from PTSD is higher than the risk of being killed in combat.
Primary care providers are in a perfect position to use their regular contact with patients to identify mental health needs, prompt follow-up with specialty care, and periodically reassess if patients are getting the services they need.
In addition to increasing attention to basic screenings before routine check-ups, providers can work with community resource and mental healthcare providers to improve the referral process and help patients overcome barriers to care access that may impede proper treatment.
Developing these relationships – and creating a mental healthcare checklist for providers to follow during patient consults – could significantly improve patients’ ability to manage their own health.
Coordinating care for pediatric patients and their caregivers
Pediatricians already employ some of the most well-developed screening and service protocols available, due to the nature of the milestones that children reach during their development. But care coordination is still an inexact science, leaving children and their families open to gaps in care.
Providers may wish to borrow a few workflow ideas from successful pediatric patient-centered medical homes (PCMHs) in order to bolster their population health management strategies for this unique group of patients.
Researchers from Texas A&M University’s School of Public Health and Texas Children’s Pediatrics in Houston suggest that providers could improve their pediatric care by implementing processes to address childhood obesity – a leading factor in the later development of chronic disease – and mental health needs, as well as boosting their knowledge of how to care for children experiencing emergency situations like seizures and concussions.
Adding a home visitation expert or social worker to the care team, especially one who is familiar with languages other than English spoken in the local community, can help to assess whether or not children have safe home environments free from neglect, contaminants, potential accidents, or abuse. A home visit can also help providers understand a child’s chronic disease management routine or identify unhealthy behaviors.
Boosting screening rates for hepatitis C patients
Hepatitis C (HCV) can produce devastating complications for patients who do not receive treatment, yet it is one of the most easily forgotten chronic diseases. Nearly three million people live with the long-term viral infection, and close to a quarter of them may develop cirrhosis of the liver within three decades.
Yet shockingly, less than ten percent of eligible safety net patients are screened for the condition, and 75 percent of those infected with the virus may not be aware of it. Fewer than 20 percent ever receive appropriate treatment.
Diagnosing this “silent epidemic” is a “public health imperative, said Erica Turse, DO, MPH, from the University of Mississippi Medical Center earlier this year. "HCV screening can reduce health inequities due to undiagnosed, untreated infection,” she added.
The guidelines for screening patients are straightforward. According to the US Preventative Services Task Force, all patients born between 1945 and 1965 should receive a one-time screening. Patients with a history of injection or intranasal drug use, patients with hemophilia, those that experienced a blood transfusion before 1992, and those receiving tattoos at unregulated locations should be tested for the virus.
Reminding clinicians to ask a few basic screening questions to patients at heightened risk of infection could easily increase detection and treatment of the disease, which is often asymptomatic.
One recent study found that more early screenings and comprehensive treatment could produce $824 billion in social value, and the healthcare system would break even financially within a decade.
Addressing food and housing insecurity for vulnerable patients
Only a fraction of a patient’s health is determined by the clinical care she receives at her primary care provider, specialist, or hospital. The majority of her wellbeing is related to her lifestyle choices, employment status, living situation, and community resources, but providers are just starting to integrate information on these social determinates of health into their care protocols.
“While patients' vital signs provide a glimpse into their physical wellness, we lack analogous information about the neighborhoods in which they live, learn, work, and play—patients' community vital signs,” says an editorial published in June in the Journal of the American Board of Family Medicine.
“Community vital signs, such as poverty level, education attained, or employment status could be independent social determinants of health, or they could be indices of these factors. There is a real need for research to understand the interplay of individual and neighborhood characteristics, and which of each are most important for understanding health outcomes.”
Not every provider will be able to purchase and implement a new electronic health record that can easily generate and accept standardized socioeconomic data, but every clinician can have a two-minute discussion with high-risk patients about their access to healthy food choices, their concerns about housing or employment stability, and the safety of their home environment and personal relationships.
Healthcare organizations that apply these population health management techniques consistently may be able to see measurable improvements in chronic disease management and long-term outcomes without breaking the bank.
Improving screening rates, education, and provider engagement with individual patient needs could be the ideal low-cost way to kick start a population health management initiative, generate quick returns, and erase lingering doubts about the importance of helping all patients access and benefit from high quality, coordinated care.