Healthcare Analytics, Population Health Management, Healthcare Big Data


Using Health IT to Meet Medicaid Population Health, Socioeconomic Needs

Health IT tools are instrumental in helping Medicaid providers manage population health and meet the high socioeconomic needs of complex patients.

Source: Thinkstock

Despite the fact that one out of every five members of the United States population is covered under Medicaid, providers dedicated to serving this segment of the market can often feel as if they are operating in a slightly separate world.

Distinct regulatory and reimbursement programs, coupled with eligibility structures highly individualized on the state level, can lead to a sense of fragmentation as population health management initiatives focus on the evolving commercial market and needs of aging patients moving into Medicare.

And as political wrangling over work requirements and funding levels sparks passionate debate about the fundamental role of safety net programs in American society, it can be challenging to design and implement programs that can produce positive results in a difficult environment.

Along with the uninsured, Medicaid beneficiaries are among the highest-need patients that most providers will see. 

Medicaid eligibility is calculated in reference to the Federal Poverty Level (FPL), which stands at a yearly income of $12,140 for individuals and $25,100 for a family of four, as of 2018.

Each state has its own formula for determining the income level that will qualify children and adults for Medicaid or CHIP eligibility.  Typically those levels still represent extremely meager takings for individuals and families - many of whom are already working full time or part time jobs.

North Carolina and South Carolina are among the eighteen states that have declined to expand Medicaid under the Affordable Care Act, leaving their Medicaid eligibility criteria relatively limited. 

In North Carolina, just over 2 million residents benefit from Medicaid, according to the Kaiser Family Foundation, while South Carolina has around 1 million beneficiaries.  In each state, about half were children up to 18 years old.

Between the two states, an additional 300,000 people are currently experiencing a coverage gap: they are ineligible for assistance from Medicaid due to their income levels, and yet they do not qualify for premium tax credits that may allow them to participate in the commercial insurance exchanges.

Researchers, public health officials, and healthcare stakeholders resoundingly agree that living in poverty, or just above the federal definition thereof, has a profound effect on health. 

From housing instability and insufficient access to food to educational disparities and interpersonal violence, the impacts of lower incomes on long-term wellness have been well documented.

Providers who primarily treat Medicaid populations are very well aware of the direct correlation between socioeconomic security and the ability to engage in healthcare.

“By definition, Medicaid families are in a different socioeconomic strata than privately insured patients,” said Dr. Marian Earls, a pediatrician and Deputy Chief Medical Officer of Community Care of North Carolina.

In a former practice, where 96 percent of patients were on Medicaid and the rest were uninsured, Earls and her patients faced the realities of socioeconomic insecurity every day.

“If I wrote a prescription for an ear infection and sent the parent out of the door with it without any other questions, I wouldn’t know if that family was living in a shelter and didn’t have access to a refrigerator for the medication, or if they didn’t have transportation to the pharmacy, or if they couldn’t even pay for the medication to begin with,” she explained to

“If I didn’t ask those questions and try to help that family work around those issues, then I really haven’t done anything for the child at all.”

Marian Earls, MD, Deputy Chief Medical Officer of CCNC

Marian Earls, MD, Deputy Chief Medical Officer of CCNC

Source: Xtelligent Media

Outside of the Medicaid environment, however, the healthcare system’s financial backing seems to be just waking up to the reality of these challenges.  

A deeply entrenched fee-for-service healthcare delivery environment has meant that healthcare providers haven’t had strong financial incentives to address these factors that may limit medication adherence, successful chronic disease management, and appropriate child development.

In the fee-for-service world, providers received payment for the services they delivered, regardless of whether or not the patient was ultimately able to benefit from those actions. 

Because a full appointment calendar equated directly to more income, they have also lacked the time to invest in meeting non-clinical needs for patients struggling to stay healthy.

And before the Affordable Care Act, commercial insurers had less incentive to focus on the holistic care of high-needs populations, because they could simply deny coverage to individuals deemed too great of a risk.

That mentality is changing in the commercial insurance environment as the ACA encourages providers and payers to move towards value-based care as more of a default position, and as big data analytics allow for greater visibility into population patterns and the impact of interventions. 

With prevention and health maintenance taking on a larger financial focus, stakeholders are now embracing the notion that the social determinants of health are responsible for much more of a patient’s wellbeing than clinical care. 

Many are now working speedily to implement population health management programs that take a much more holistic approach to care delivery.

As they do so, they may wish to understand how Medicaid providers have been successfully addressing the social determinants of health with scant resources at their disposal – and how emerging technology strategies are making it just that little bit easier to engage in effective, efficient, and impactful population health management for highly vulnerable patients.

Using health IT to understand and codify socioeconomic needs

In pediatrics, as well as in adult primary care medicine, conversations with patients and their families can often give providers more insight than lab tests or even physical exams.  These conversations aren’t always comfortable for the participants, but they can uncover vital clues into how to best care for patients.

“The social situation, emotional health of a family, and the health literacy levels of the caregivers are so integral for understanding how to provide the right care,” said Earls. 

“It might be especially important in pediatrics, because your patients can’t talk to you directly for the first few years that you’re treating them.  The family situation is really in your face, because the child is relying upon their parents or guardians for all of their needs, and the family is the one interpreting the child’s needs for you.” 

But the data resulting from these valuable conversations isn’t always codified in the electronic health record (EHR) in a manner that allows organizations to create standardized and accessible interventions, pointed out Dr. Alisahah Cole, Vice President and System Medical Director of Community Health at Atrium Health, formally Carolinas HealthCare System.

“These conversations are often somewhat informal, due to the nature of what is being discussed, and that means they have been documented informally, too,” she said.  “Some people were adding the information to the visit note; some were using a social and family history template.  Our care managers have a separate note type to use, so they were putting the information in there.”

“We wanted to start matching up patients with available community services to meet some of their needs, but we were finding it difficult to reliably identify those needs due to the variations in documentation.”

Earls found similar challenges when CCNC was ramping up its socioeconomic interventions.  CCNC, which provides analytics and care management infrastructure to support the primary care ecosystem in North Carolina, currently relies on claims data for the majority of its initiatives.

“That’s because most of the data around social determinants screenings isn’t structured in the typical EHR system,” she said.

“There are more than 200 EHR vendors in use in the state, which paints a very complex picture for anyone trying to extract data from these systems at scale.  Most of the pediatric practices in NC are not owned by one of the big hospital systems, so they have independent EHRs.”

“Most of the data around social determinants screenings isn’t structured in the typical EHR system.”

Collecting timely, accurate data on Medicaid patients and their socioeconomic needs becomes even more challenging when considering that some degree of instability is a very common fact of life for individuals hovering around the poverty line, added John Supra, VP of Solutions & Services at South Carolina’s Care Coordination Institute.

“Many providers are engaged in some sort of risk arrangement with Medicaid managed care organizations (MCOs), which rely on attributing patient populations to specific providers for management,” Supra explained.

But in practice, the way an MCO defines an ‘established relationship’ with a provider for financial reasons doesn’t always match up with the way patients are interacting with the care delivery system, he said. 

“The MCO will pass out gaps-in-care reports and attribution lists to their providers, but many of our individual physicians are saying, ‘Half of these people aren’t my patients.  I don’t know them and I don’t know how to get in touch with them.  Why am I being made financially responsible for them?’”

Some of these patients may be matched correctly at the practice level but not to the right individual clinician, said Supra, which is a problem that is relatively easy to solve. 

“When we start moving into the other brackets of data, however, we can run into much more complex issues with attribution and identification,” he said.  “Now we’re talking about the patients who might have seen one provider at one location a few years ago, then another physician in the next town over, but there clearly isn’t a lot of attachment or engagement to a particular part of the network.”

“Then we have the people who have been attributed into our network and to a provider, but we have basically no information on them.  Maybe they showed up in an ED years ago, but that’s it.  We don’t know what their status is, what their needs are – sometimes we don’t even know if their address is current or how to contact them.  We can’t find them.”

These patients may be transient, they may be in and out of institutions, or they may simply be unable to afford services.  Either way, “they are likely in need of a lot more than what they’re getting,” he said.

“We need to work hard to ensure we can find them and address those gaps – because the providers are going to be financially responsible for these outcomes either way.  That’s a very strong reason to bulk up our technology and analytics capabilities and work with communities to get these patients the care they need before the next contact we have is from the inpatient setting.”

What Are the Social Determinants of Population Health?

Identifying Big Data Sources for Population Health Management

Enlisting community resources to contact and care for patients

Medicaid providers have had to get creative to fill in the holes in their datasets before they can even start delivering comprehensive population health management services.

“We’ve had to be innovative when it comes to finding the patients attributed to certain providers,” said Supra.  “We very quickly realized that we needed to use different ways to start grouping them and finding better methods of getting in touch with them.” 

“We don’t know what their status is, what their needs are – sometimes we don’t even know if their address is current or how to contact them.  We can’t find them.”

“So we would start asking different questions.  Who looks like a family?  Do we have a group of kids in the same neighborhood?  Can we talk to certain schools in a particular area to see if those kids are still there?  Can we engage with a certain social service agency to reach people who look like they might have some socioeconomic challenges and be reaching out to these places for help?”

Dr. Cole at Atrium Health has also recruited community leaders to help identify gaps in care and define new opportunities to get proactive about the social determinants of health.

“We embarked on our Community Health Improvement Study in which we worked very closely with our local health departments and other hospital partners to focus on the social determinants of health in a more detailed way than the typical community health needs assessment,” she explained.

“In each of the counties we serve, we worked with UNC Chapel Hill Institute of Public Health to create a visual story map around the social determinants, particularly the top 12 that have been shown to have the most impact on health.”

The visualizations helped reveal that certain neighborhoods within each county faced significantly more challenges than other regions.

“When we overlaid some of our patient data on those maps, we could very easily see that the communities with higher socioeconomic needs also had higher rates of diabetes, unnecessary ED utilization, readmissions, and obesity,” she added.

“When you identify needs and opportunities to such a degree, you can start to bring that data back to your social support organizations, schools, business communities, and provider partners and align your work around high-priority solutions.”

Identifying the patients in need of enhanced services is only one half of the battle, however.  Connecting those patients with community organizations that have the capacity to help requires changing some internal strategies around managing data and relationships, too.

“Every healthcare organization has a notebook,” said Supra.  “They write down community aid groups that have been helpful, or they have the names of a few key people at the social services organizations that are good to call when you need something.  Our notebook made it into a database a few years ago, but it’s basically the same thing.”

Alisaha Cole, MD, VP and System Medical Director of Community Health at Atrium Health

Alisaha Cole, MD, VP and System Medical Director of Community Health at Atrium Health

Source: Xtelligent Media

Care managers at Atrium used to rely on a very similar strategy, said Cole. 

“Our clinical care managers had something they called ‘the crystal ball.’  It was an Excel spreadsheet where everyone could add information on social support agencies and the best people to contact for certain needs,” she said.  “It was very helpful, but it wasn’t standardized and it wasn’t sustainable.  No one was in charge of it, particularly, and it wasn’t kept up to date.”

Coupled with fragmented EHR data documenting socioeconomic needs in multiple locations, if at all, many providers can feel very poorly equipped to refer individuals to necessary services – let alone track if those services were accessed appropriately and follow-up with patients or their caregivers.

“The inability to do referral tracking is striking,” lamented Earls.  “Even when you refer children to resources at their schools or early intervention programs, they are currently so separated from the medical system that it’s very difficult to follow up.” 

“When you’re talking about developmental screenings, you might be referring to an occupational therapist or a speech-language therapist, and it’s very important to be able to track what is happening with the patient when he or she engages with those resources.”

“There weren’t very good systems to accomplish that when we were on paper, either, so it’s not as if we have taken a step backwards.  But we’re not moving forwards very quickly, either,” she said.  “We can hardly communicate effectively with each other, never mind these other agencies.  Most of the correspondence back and forth is still taking place on paper.”

How Do Population Health, Public Health, Community Health Differ?

Using Risk Scores, Stratification for Population Health Management

Using a variety of data-driven strategies to close care gaps

For Atrium, getting rid of the static, unidirectional notebook required an investment in an innovative project called the Community Resource Hub.

The online tool allows community members to search for applicable services and enables healthcare providers to write electronic referrals for patients.

“It’s not as if we have taken a step backwards.  But we’re not moving forwards very quickly, either.”

The hub connects needy individuals to transportation services, legal aid, housing and food assistance, and other resources that can impact quality of life and adherence to healthcare recommendations.

“We can print off the information from the Community Resource Hub and give it to the patient, or we can tell them how to use the site themselves so they can access what they need at home when it’s convenient for them,” said Cole.

“For those who do consent for us to send a referral through the platform, that allows us to communicate with the social support agency.  The agency will contact them once the referral is sent, but then we have the ability to track if an appointment was made, if that appointment was kept, what applications were filled out, and if any further needs have been identified for that individual.”

The individual’s primary care provider can access that information, allowing them to have productive, accurate discussions about further needs or opportunities, she added.

Source: Atrium Health

Eventually, Atrium is aiming to integrate the option directly into its Cerner electronic health record, but that would require some infrastructure development on the part of the community and social support organizations who would be receiving those referrals if they are primarily delivered electronically, Cole said.

“We have found some gaps on the infrastructure side among our non-profit and social support organizations,” she noted. “Some of them are using a full EHR, and some are on some sort of electronic documentation system, but there are plenty who are still fully on paper and can’t accept electronic referrals.”

As the system is developed and those technical gaps are closed, Cole hopes to help create a single electronic application that would allow patients to apply for multiple services without filling out a number of different forms.

“One of the major challenges for these individuals is coordinating all of their services while facing things like transportation barriers and childcare issues and being unable to take time off work during business hours to get to five different offices,” she said. 

“A unified electronic application would reduce a lot of the need to chase down different case managers and juggle phone numbers, appointment times, and the different criteria for each agency.”

At CCNC, optimizing data-driven processes to collect more robust pediatric screening data is a top priority for Dr. Earls.

“In North Carolina, we have made developmental screening a priority since 2000.  It’s important to stress that it’s not add-on information – it’s data about these young patients that you need in order to make recommendations for their care,” she said.

“We have a very high rate of screening at pediatric well visits.  We’re at around 94 percent statewide for both pediatricians and family doctors seeing children ages 0 to 5.  We also screen for autism at 1.5 and 2 years of age, and we’re expanding our delivery of postpartum depression screenings during early infant visits.”

CCNC is also working with practices to integrate enhanced questions about family protective factors into the screening process in alignment with recommendations from the American Academy of Pediatrics.

“[This is] not add-on information – it’s data about these young patients that you need in order to make recommendations for their care.”

“Family protective factors are the emotional, social, and mental health strengths that can help them withstand stressors and help their children thrive,” Earls said.  “We know that there tends to be an inverse correlation there: families with more social determinant risks often have fewer protective strengths, so it’s important to assess both of those together.”

Pre-visit questionnaires for parents help collect data without taking up precious time during a consult, and tailoring technology strategies to the needs and capabilities of each provider organization ensures that workflows stay manageable.

“Helping people understand how these activities fit into their workflow is important,” said Earls.  “Making sure that you are not just imposing a list of new tasks with no rationale is critical, as well.  You don’t want to come up with a plan from somewhere up high and then tell everyone they have to do it, no questions asked.  The knee-jerk response to something like that is to balk at the idea, no matter what it is.”

“Our approach has been to help every practice figure out what works in their community and what works with their staff and resources.  We work across sectors and engage with organizations like the school systems, our pediatric society, Medicaid, Head Start, the public health department, and other entities that need to be involved so we can be very comprehensive in our approach.”

And at South Carolina’s Care Coordination Institute, workflow optimization meets health IT through the enterprise master patient index (EMPI), which helps detangle some of the patient attribution and identification issues that can stop a population health management program in its tracks.

John Supra, VP of Solutions & Services at South Carolina’s Care Coordination Institute

John Supra, VP of Solutions & Services at South Carolina’s Care Coordination Institute

Source: Xtelligent Media

“Our partnership with NextGate is one of the many tools we’ve employed to try to meet these challenges,” said Supra. “How do you bring on the community benefit organization to receive that information and integrate into what we’re doing?  We’re looking at how and where it touches our workflows.”

“If I want to engage with a community benefit prescription provider, I’m going to have to go back at some point to my EMPI and find out what I know about this person and make sure that whatever I’m doing is for the right individual with a common name, for example.”

The tools are matched with mobile “community paramedic” clinics that reach out to patients and provide critical services, allowing healthcare providers to take a more proactive approach to care.

Supra is also investigating a partnership with an organization that enables electronic “prescriptions” for socioeconomic services, similar to the Community Resource Hub.  This capability could further enhance community relationships and provide support for Medicaid beneficiaries in the region.

How to Get Started with a Population Health Management Program

Identifying Care Disparities for Population Health Management

Developing strong partnerships to support innovation

Just like providers need to support a Medicaid patient’s multifaceted clinical and socioeconomic needs, healthcare organizations must cultivate a number of relationships with their technology vendors, community partners, and internal stakeholders in order to see success.

Atrium Health, CCNC, and South Carolina Care Coordination Institute all play important roles as conveners in their respective communities, offering technical expertise and analytics prowess that bring their partners closer to their shared goals.

“It helps if you take the lead as the health system and offer your technical experiences where needed,” said Cole.  “Our community partners really appreciated that, especially because we are not a big, foreign corporate entity reaching into their organizations trying to make big changes to how they operate.”

“Atrium been in the community for a very long time, and we’ve made a lot of effort to collaborate in a way that helps everyone become successful.  That approach opens a lot of doors to have transparent conversations and to exchange ideas without anyone feeling bullied or like they’re losing control.”

A broad reach is also helping the large health system standardize its IT processes, Cole added.         

“It’s important to think about how health IT tools can bring all of this information together,” she said.  “Through Cerner, which is our primary EHR vendor, we’re working to create a standardized screening process that will be embedded initially with our care managers.” 

“When we finally made the decision to standardize this process, we needed to identify our partners who could help us, and your EHR provider is going to be one of those major entities that can help support a solution.”

“It’s important to think about how health IT tools can bring all of this information together.” 

Embracing a leadership position within the community is paying off similarly well for CCNC, said Dr. Earls.

“CCNC is statewide, and we have an informatics system that goes across all of the counties and networks,” she said.  “We also have a care management information system.  More than 95 percent of the primary care providers in the state are part of CCNC, so that makes it much easier to treat this as a quality improvement project at a larger scale.”

“We started in a couple of counties with practices that were very motivated to help us develop best practices, then we spread out to more of the network with the help of the quality improvement folk. That strategy has allowed us to expand our training and education in a very workable way.  Without this type of collaborative in place, it would not be as easy to see the success we’ve seen.” 

Working within the community and clearly laying out collaborative goals is the key to implementing strategies that produce lasting change, said Cole.

“Always, always include the community in your work and really listen to what they’re saying,” she stressed. 

“When we did our community health improvement study, there were some issues that rose to the top: diabetes, cancer, and substance abuse, among others.  But when we asked people about the top three things they wished we could impact, food security was on top of the list for every single community we serve.”

“So now we’ve created a food security strategy that we’ll be working on over the next three years, and we are hoping that the impacts of that will help us see improvements in some of the other areas we identified, as well.  But if we didn’t listen to the community first, we wouldn’t have known that their greatest needs were slightly different than what we identified on our own.” 

“Without that open communication, we wouldn’t be truly serving them in the way that will produce the biggest positive impact on their lives as a whole.”

Listening to all stakeholders, especially patients, and collaborating around best practices and workflow changes can help large communities innovate quickly and cohesively, agreed Earls.

“We don’t want to have every individual practice trying to reinvent the wheel and form all these relationships by themselves.  Collaboration is such an important part of systemic improvement, and that is what has made us so successful this far.”

“If everyone tried to do this on their own, it would be very slow.  Putting that infrastructure in place and working on relationships that can produce an impact across all of the different services and agencies that support children and families is incredibly important, and we’re very proud of the progress we have made so far.”

This article was originally published on April 20, 2018. 


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