By Moray Joslyn, Senior Director, Quality and Performance Improvement
In the population health department, a care coordinator is speaking to a patient in Spanish. He describes the benefits of a home testing kit for colon cancer screening and gives step-by-step instructions on collecting a stool sample. The patient does not recognize the phrase ‘muestra de heces’ (stool sample), but undeterred, the care coordinator offers two or three alternatives, finding one in the patient’s vocabulary.
Across the office, another team member receives an alert. Last night, one of SBH’s 16-year-old patients was treated and released from an emergency department in a different borough following a suicide attempt. Reviewing medical records, the team determines that while the patient does not currently see a behavioral health provider, they receive care from our pediatricians. The team immediately consults the pediatrician and begins outreaching the patient to bring them in for care straightaway.
The work is diverse, yet at its core is the unifying aim of providing proactive and excellent care to SBH’s patients. The goal is to keep patients healthy and avoid preventable hospitalizations. This is methodological and data-driven work on an industrial scale implemented through individual patient-centered ways.
Cookie-cutter approaches like robo-calls cannot pivot their language and motivate patients for change like healthcare workers in the community.
Over the last decade, the term “population health” has emerged to describe a partnership approach among healthcare systems, agencies, and organizations that work to improve health outcomes for the communities they serve. Focusing on cohorts, population health nimbly tackles multiple issues to keep all members in a geographic area or insurance plan healthy. Central to this approach are three pillars: data analytics, care coordination, and clinical integration.
Managing the health of a population requires an in-depth understanding of its demographics, health conditions, and healthcare utilization patterns. Also vital is an understanding of how social determinants of health create health barriers in the community.
SBH Health System stands in the center of the Belmont and East Tremont district of the Bronx. Home to 87,476 residents, the district comprises a population that is 67 percent Latino and 25 percent Black. The population is young, with 43 percent of residents being under the age of 25, compared to 30 percent in the city.
Health outcomes in the community are poor. The adult obesity rate is 36 percent compared to an NYC rate of 24 percent, and 22 percent of residents have diabetes, which is double the NYC rate. Avoidable hospitalizations are high in Belmont and East Tremont, at a rate of 2,855 per 100,000 adults compared to 1,033 per 100,000 in NYC. High rates of poverty and low access to healthy food compound these challenges.
Analysis of hospital medical records and claims data allows the population health team at SBH to target these issues methodically. Focusing on disease categories and sub-populations, population health analysts identify all patients with a chronic condition like diabetes mellitus to confirm they have received the clinically required care. They also identify patients due for preventive screenings like breast cancer or colon cancer screenings. The output is a list of patients for care coordinators to outreach and engage.
This data-driven approach is founded on the Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics, which convert clinical guidelines into operational specifications. The HEDIS metric for comprehensive diabetes care stipulates which patients require a hemoglobin A1C test and at what interval. Similarly, the HEDIS metric for cervical cancer screening specifies the required test and interval for different age groups of women.
HEDIS quality metrics set a standard and allow performance to be measured and improved. As a result, insurance companies use these metrics to drive star ratings. However, the operation focus should always be on delivering excellent patient-centered care. If hospitals do the right thing for the patient, the rest will follow.
A crucial unseen element of every analyst’s work is data quality assurance. Every patient list needs scrubbing through a population-specific lens before outreach begins. Have any patients already had the test within its specific timeframe? Have any patients had a full hysterectomy? Is anyone on the list recently deceased? Is anyone transgender, and what does that mean for this particular metric? Algorithms can only take it so far. A human eye must ensure that data used for outreach calls do not cause any unintended harm.
The second pillar of population health is care coordination. Communicating directly with patients and families, care coordinators are healthcare professionals with outreach and engagement expertise. Their work involves deliberately organizing patient care and communicating information among all care providers to achieve safe and high-quality care (AHRQ, 2021).
The keyword is deliberate. Care coordinators deliberately respond to care alerts and work through lists of patients requiring a care service or screening to ensure no patients fall through the cracks. They intentionally link patients to community resources and work to reduce barriers to care. Every Tuesday, the care coordinators receive a list of patients struggling to adhere to their medications. These medications are vital to controlling their serious chronic conditions, but the patients have previously missed several doses, and now pharmacy data shows they have run out. As a first step, the care coordinator phones the pharmacy to confirm that the patient has not been in and has refills available. If there are no refills left, the next step is to speak to the prescribing provider to arrange a refill and perhaps a clinic visit if a review is required.
Now the care coordinator phones the patient, and while the process may be routine, the calls are not. The first patient just forgot and is grateful for the reminder. The second call evolves into education on the importance of taking maintenance medications every day. Other calls identify barriers with getting to the pharmacy or paying for co-pays. The team seamlessly switches between different communication styles and motivational techniques as each issue arises.
Care coordination for population health differs significantly from other forms. Clinic navigators are reactive, scheduling referrals on a case-bycase basis, where population health is proactive and systematic. Health homes provide ongoing support to enrolled high-risk patients, where population health engages many patients for short, focused interventions. Distinct skills are required to successfully outreach, engage, and motivate patients for change in this way.
Medication adherence efforts reveal the importance of clinical integration as “ Care coordinators deliberately respond to care alerts and work through lists of patients requiring a care service or screening to ensure no patients fall through the cracks.” population health’s third pillar. Clinical integration is the act of coordinating patient care across conditions, providers, settings, and time to achieve care that is safe, effective, and timely. Excellent, high-quality healthcare requires all parts of the healthcare system to work together in a patient-centered way.
Closing a gap in care for breast cancer screening requires primary care to place an order, care coordinators to engage patients, and radiology to provide a mammogram. It is a similar chain of events for each preventive screening and care service. Clinical integration is the invisible glue that holds everything together. When it works, patients experience effective care. When it does not, patients fall through the cracks.
Population health has a unique role in clinical integration. Working with patients across services, systems, and processes, the team directly encounters the barriers to excellent health care. Patients tell them why they were unable to schedule an appointment or fill a prescription. They see the cracks firsthand. The trends that emerge are like striking gold for SBH’s quality improvement team. Their resulting quality assurance and performance improvement activities make a real difference to patients’ care experiences and prevent gaps from opening in the first place.
It is easy to align with population health’s unifying aim of providing proactive and excellent care to SBH’s patients. It is a goal that SBH providers, patients, and community members aspire to and have worked towards for many years. The emergence of actionable data and practical implementation approaches mean that population health has a future as bright as SBH’s patients