Reimagining population health by putting the healthcare consumer first
Collaboration is critical to make population health something more than a buzzword. Organizations need to work together in order to understand the needs of the population and how to extrapolate that for each patient. That means, for example, clinics working with community associations and faith-based organizations – figuring out the best way to meet people where they work and live, and use that connection to encourage them to get actively involved in the recommendations that will help better their outcomes.
As anyone who works in healthcare knows, facilitating that kind of collaboration outside the four walls of the examining room is not without challenges, and in order to get there, you have to have the right people, the right process, and the right technology in place.
The right people, process, and technology enable collaboration for better outcomes.
Population health cannot be implemented without the right people on board, both in clinical and non-clinical positions, who understand the goals and are working together to reach them.
Process-wise, it’s about evidence-based care coordination. The right care plans need to be in place, not just for the different populations but also for individuals. And it is also critical that those best-practice plans are then consistently applied so follow-ups happen, information is shared, and all potential loops are closed to reach that true continuum of care.
Care management plans can make a world of difference. In fact, study after study suggests that when it comes to hypertension, obesity, diabetes, and asthma, having a coordinated care team can significantly improve outcomes and lessen the number of healthcare resources required to help these individuals stay healthy. For example, an approach that considers patients’ weaknesses and enables coordination between patient and care team is more apt to succeed as opposed to telling an obese patient to lose weight by eating less and exercising more.
What is the right way to implement these processes? Strong physician engagement is necessary from the start—with that alignment in place, others in your organization will follow. Yet, even with the right people on board, who are committed to putting a good process in place, one that offers that comprehensive care coordination, you still need the right technological support to sustain it.
This brings us to technology. Technology is the enabler, not the starting point. There are plenty of population health management tools on the market today - enough to cause any hospital chief information or technology officer confusion and fatigue in selecting the right tool to enable the targeted outcome. In order to select the platform to make your population health effort effective, two key factors to consider are: data accessibility and interoperability.
“To enable a seismic shift to a value-based system, healthcare will need to be transformed. The traditional settings of care along with the existing types of care models will undergo major disruption, resulting in improved access, better health outcomes and lower cost of care. A design thinking, human-centered approach to managing population health is vital to deliver a ‘consumer-grade’ experience, convenience and enable insights to help patients and clinicians make more informed decisions.” - Praveen Soti
“Never before has there been such intense focus on healthcare entities to provide high-quality care at lower costs while maintaining financial viability. Population Health presents an opportunity to address the outcomes at the patient and group level by assimilating patient data from disparate sources, stratifying patients based on risks, understanding adherence and compliance barriers, and coordinating care beyond the ‘four-walls’ utilizing a digitally-enabled patient-centric approach that draws on clinical and non-clinical teams from provider, payer, community and service provider organizations.” - Amar Prasad
Capturing a patient journey for HONDA through a journey map
Patient journey maps help capture a patient’s experience and provide a holistic view of various touchpoints for their care team. It helps a solution team to gather and analyze information from various sources empathetically - from the patient’s perspective - and chart opportunities to bridge gaps and improve patient and provider experience. Once a journey like this one, for a patient with a condition we call "HONDA" is defined, a patient journey map can be extrapolated to a broader population, helping organizations design health systems more effectively to predict, prevent or treat the disease state.
Persona: Sam suffers from hypertension, diabetes, obesity, and asthma; he is also non-compliant with his care plan. In short, Sam is a HONDA patient and needs help. The chart below shows some of Sam's experience as a patient, his needs, and ideas for how to help him live a healthier lifestyle.