Healthcare Analytics, Population Health Management, Healthcare Big Data

Population Health News

Safety Net Population Health Management Means Doing More with Less

The safety net is a challenging proving ground for population health management, but innovation that succeeds there may be able to succeed anywhere.

By Jennifer Bresnick

- For healthcare organizations of any size, type, and specialty, every dollar always counts.  The immutable bottom line regulates all activities, from technology purchases to staff salaries to what gets served in the cafeteria each day. 

Population health management and community care

Healthcare is a business, after all, and what seems like the pointless pinching of a few pennies here and there could have significant implications for how long a provider can keep their lights on.

For safety net providers serving the neediest, most vulnerable patients in the country, the almighty dollar might just count a little bit more than usual. 

Often underfunded yet charged with the task of caring for some of the most difficult-to-manage patients available, safety net organizations are already very used to conjuring up complex, quality care while operating on a shoestring budget.

With high demands for quality and volume, but little access to the advanced population health management technologies, predictive analytics, and cutting-edge data lakes that help coordinate care at academic medical centers and top-ranked integrated delivery networks, the primary mission of the Center for Care Innovations (CCI) in California is developing creative, low-cost ways for community health centers to better serve disadvantaged populations.

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Population health management may be a difficult undertaking at the best of times, but Ray Pedden, Strategy and Innovation Consultant at CCI, doesn’t think providers need a seven-figure budget to make progress in the battle to achieve better health.

What they do need, however, is a thorough understanding of their patients, the ability to approach population health in a holistic manner, and a willingness to engage in creative problem-solving without breaking the bank.

“Community health centers and community hospitals have always taken in everyone who walks in the door,” Pedden told  “If a patient presents with a problem, we’re going to figure out how to take care of them no matter what.  We don’t typically have endowments to rely on.  We have to figure out how to scrape by.”    

“That means we need to focus on developing the most effective and efficient ways to deliver care, and we have to innovate out of necessity.  There is a lot of pressure on the safety net right now, with Obamacare and the expansion of Medicaid – and a lot of pressure on us to expand our capacity to care for patients.  Innovation isn’t a choice.  It’s what we have to do to keep the doors open to vulnerable people.”

Exploiting the give-and-take of innovation

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CCI, which is based in Oakland, California, provides grant programs, education, and resources to help community health organizations create novel population health management strategies, develop their big data analytics capabilities, and foster patient engagement, patient-centered care, and improved chronic disease management.

Working with cash-strapped public providers isn’t always an easy task, especially when outside funding opportunities are few and far between.

“We take advantage of committed souls, if you will,” Pedden admitted with a laugh.  “When it comes to financing and developing new strategies, I try and play upon the desire for people in organizations to do good for the right reasons.”

But altruism isn’t the only motivation for health IT developers with new ideas in hand.  Pedden pitches collaborative projects as a win-win situation.  Not only do safety net providers get the tools they need to do their jobs better, but vendors and entrepreneurs get the opportunity to road-test their products in one of the toughest environments around.

“We've talked to a lot of people with the desire to create innovations and show off how they can work in the safety net at little or no cost to the providers involved,” Pedden explained.  “So I might talk a developer into writing a program for us that will allow us to interface between a legacy system and a more modern, commercial EHR.”

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“I’ll tell them, ‘If you can successfully implement something like that in the safety net, you can do it in organizations with a more commercial focus.  So how about you use us as a demonstration platform to gain the experience and knowledge you need for your product, so that you can sell it to the commercial organizations and make some money?’”

Early success, sky-high ambitions

One of CCI’s recent projects is a pilot deployment of Meducation by Polyglot, a system that allows providers to generate personalized medication adherence notes for patients in their first language. 

Patients with limited English proficiency are extremely common in California, one of the nation’s most diverse melting pots.  Data from the 2000 census found that nearly 40 percent of California residents spoke a language other than English in their homes, with 20 percent of that population stating that they do not speak English very well. 

In a state where more than half of all public hospital and health system patients have limited English skills, providing educational materials in languages other than English can be the difference between a successful hospital stay and an expensive preventable readmission.

“We see a lot of indigent people, people who don't speak English as their primary language, and those who may not be legal citizens,” said David Smith, PharmD, from San Francisco General Hospital. “So it's difficult to do a lot of consistent patient outreach once they leave the hospital, and it’s not easy trying to empower them to manage their own health.”

“We have large numbers of Mandarin, Cantonese, and Spanish-speaking patients, and we also have Tagalog-speaking patients and a number of other populations,” he added. “In general, it’s difficult for them to understand all their medications.”

Instead of trying to translate medication information into Spanish or Mandarin by hand on an ad hoc basis if and when a fluent staff member was available, SFGH staff members can instead provide documentation to patients in more than a dozen of their native languages.  The materials are written at a fourth or fifth grade level of health literacy to maximize understanding, and the results among high-risk patients were swift and impressive, Smith said.

“We were able to perform the intervention with 39 patients, and their readmission rate was eight percent. For the control group of 31 patients, there was a 26 percent readmission rate,” he said.  While the results were “probably more dramatic in a very small sample size than they would be if we included thousands of patients,” there is no question that small, patient-centered changes can produce measurable results.

CCI is making the little things count in Sonoma County, too, Pedden said.  As the industry starts to get to grips with the idea that socioeconomic disparities and behavioral health concerns can significantly impact the success of clinical care, the task of integrating community services into the primary care ecosystem is taking on a new sense of urgency.

“We’re beginning a project in Sonoma County for patients that need care for more than just a presenting problem,” said Pedden.  “These are patients with social needs in their lives that have to be addressed, like food security, or access to behavioral health services or counseling.”

“The question for the healthcare provider is, ‘How do I, once I identify the food security issue or the behavioral health issue, connect that patient to a social service agency in an efficient way?  How do I do it with a sensitive understanding of the culture of the patient?  How do I package the data that the social service agency needs, and how I find out that the problem has been addressed on their end before the patient comes back into my office?’”

Connecting the dots across the care continuum

The answers to those questions are split between two of healthcare’s greatest challenges: workflow and technology.

“It’s difficult to connect all those data points, but that’s what we have to do in order to improve the level of care we’re delivering,” Pedden stressed.  “The typical method of communication is post-it notes and phone calls.  That’s how we’ve done it in the safety net – and I’m sure we’re not the only ones who do a lot of these things like that.  But it doesn’t engender great two-way communication.”

The Sonoma Country project will “enable an electronic environment that allows for complete two-way communication between our social service agencies and our healthcare organizations, so that we can create electronic pathways – sometimes asynchronous, sometimes in near real-time – across our care continuum,” he explained.

The goal is to integrate social services, behavioral health providers, and other key partners into the process of treating the whole patient

“We want to bring social services agencies to the table as first-tier providers in the healthcare world,” he said.  “Our hope is that we not only improve the delivery of care, but we begin to understand and to quantify the impact of the social determinates of health on the direct delivery of care.”

A penny saved is a lesson learned

Driving meaningful change in the safety net – or anywhere else, for that matter – is a difficult endeavor, and one that requires a certain “hardheadedness” to get results, Pedden says.

“You have to be committed to better outcomes.  You have to be unafraid to fail, because you’re going to have to keep pushing buttons when you want to achieve something.”

“We are going to change the world – and we’re going to change healthcare,” he declared.  “The question is whether you want to contribute or you want to follow along in our wake.  Sometimes your failures can be as important as your successes, so don’t be afraid to try new strategies to see if they work.”

Creativity doesn’t have to be expensive, either, he pointed out.  “You can set up an ‘innovation center’ with a marker and a pad of paper.  All you have to do is bring people together into the same room so think through your processes and come up with ways to make your workflows more efficient.”

“I'll never forget the time I was walking through one of the back hallways of the pulmonology clinic at San Francisco General Hospital, and I saw these poster-sized pieces of paper stuck into the wall,” he recalled.  “And on those pieces of paper, people were writing ideas about improvements – and other people were coming by and changing them or adding to them, and there were post-it notes everywhere saying ‘this is a great idea; let’s do this,’ or ‘I don’t think this will work and here’s why.’”

“Everyone was part of this discussion, sharing their ideas and their data and experiences.  It wasn’t a fancy PowerPoint presentation or a week-long conference.  It was all being done on these pieces of paper where anyone who was walking by – doctors, nurses, medical assistants, or janitorial staff – could write their latest idea or innovation or observation on care delivery.”

“That’s the grittiness of the safety net,” he added.  “It’s amazing to see how engaged these people can be.  You don’t need millions of dollars to get ideas flowing.  You need five bucks for a pen and some paper, and a willingness to tap the ingenious resources you already have in the people working for you.”


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