How better digital communication can improve population health management

October 20, 2020 - by Meera Vadali

Looking to part with the idea of “sick care,” a growing number of hospitals prioritize the proactive approach — population health management.

We owe a majority of our health status to factors outside the domain of traditional medical care. Social determinants of health, or SDOH, include environment, race, gender,  genetics, education, and income. 

CHCs and FQHCs have always been intrinsically aligned with population health management. For other healthcare organizations, it’s taken time for mindsets to shift. 

Value-based care incentivizes a proactive approach

With the rise of value-based care contracts, reimbursement is tied to patient outcomes rather than fee for service. This incentivizes proactive approaches — the foundation of population health. For example, closing gaps in care could save health systems up to 500 billion dollars a year

Unfortunately, the sickest five percent of Americans contribute to 50 percent of total healthcare costs because they don’t receive the care they need at the right time.  Earlier intervention for a large majority of these sick patients will improve outcomes and reduce costs. 

Digital communication plays a key role in patient outreach and engagement for population health management strategies. 

Identify at-risk groups

In order to address gaps in care, health systems must identify vulnerable groups based on population health risk factors by optimizing the data stored in the EHR. With the help of a patient communication hub that integrates with the EHR, specific gaps in care can be found and targeted through personalized patient outreach.

For example, use data to identify patients who are not up to date on vaccinations and create targeted population health message campaigns around receiving vaccinations to close the gap in care.  

Help patients manage their care 

Texting has established itself as a flexible, convenient, and effective way to engage patients in their care. Especially for chronic care management and treatment plan adherence, texting has the power to educate, inform, support, and guide patients in their health care journeys. Similar to immunizations, texting can promote population health and address medication non-adherence, low preventive screening rates, and improvements in chronic condition risk factors. 

A 2017 study from researchers at Washington University in St. Louis found conversational messaging improved the rate of self-reported medication adherence. Patients received reminders to take medications and were prompted to explain reasons for missed doses. If problems arose, providers could triage the situation in real-time. 

Increase access through transportation 

Some patients can’t receive care because they just can’t get to it. Transportation issues, including lack of a vehicle, contribute to nearly 30 percent of no shows. As a result, more than 3.6 million individuals forego medical care each year, according to the American Hospital Association. This particularly affects the elderly, who listed transportation as the third most common barrier to accessing health services. 

Help patients get to the door by arranging the ride through a ride-share program. With a patient communication platform, automation allows patients to request and coordinate a ride all via text.  

Leverage telehealth

Telehealth increases access to care while reducing ER visits, rehospitalizations, and the total cost of care. For example, Frederick Memorial Hospital created a telehealth program geared toward population health improvement, piloting it on a group of 150 high-risk patients with chronic conditions. Within two years, the program cut ER visits and the cost of care for program participants by half and reduced rehospitalizations by 90 percent. 

The importance of reducing unnecessary ED utilizations in population health management can’t be understated. Patients continuously finding themselves in in-patient settings and ERs drive up the cost of healthcare. Preventable ED visits amounted to 8.3 billion dollars as of 2019, an increase of nearly four billion dollars since 2010. Increased readmissions and ER utilization also display a decline in health outcomes rather than an improvement — something value-based care won’t reward. 

Engage patients post-discharge

Thirty-day hospital readmissions have come to the forefront as a value-based care outcome metric. Research shows that when patient activation measure (PAM) scores — a way to assess patient engagement — are higher, the odds of hospital utilization within 30 days of discharge decreased by 18 percent. 

Lower stages of PAM indicate patients do not feel an active role is important in their health care and are not confident in their knowledge to make health-enabling decisions. Giving patients an avenue to ask their questions and receive any education, support, or guidance needed during recovery periods can improve PAM and hospital readmissions as well. 

At WELL, we believe digital patient communication is the key to better population health management. 

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