What It Takes to Improve Population Health Outcomes
Solving the complex population health equation is like working on a 5,000-piece puzzle with multiple people. It takes a long time. You generally have all the pieces, know how it should look, and know who should be involved, but figuring out the right combination of pieces and people is where things get challenging.
Some argue you should start with putting all the edge pieces together to get a structure. Others believe you should find an image and build onto it.
From the outset, it’s hard to know whether the chosen direction is best in the long run.
If you’re someone who cares about population health, you’ve likely had some of these same thoughts and conversations. It’s no easy feat.
Although challenges persist, change is happening. COVID-19 paired with technology advancements catapulted organizations into prioritizing population health in new ways.
To discuss, we gathered three brilliant minds in our latest Relevant Health Roundtable to hear about how they approach and address the health of their populations. We had the pleasure of hearing from:
- Nina Prabhu, Vice President of Dental Services, Delta Dental of Minnesota
- Danielle Robertshaw, Senior Medical Director, Hennepin Healthcare
- Cheryl Matter, Vice President, Population Health, Seniorlink
All three brought valuable perspectives, sharing their thoughts on the role of collaboration and data, care support structures in caring for those most vulnerable, and more. Read on to get a snippet of their conversation. If you want to jump right into the full discussion, check out the panel on-demand here.
Innovating During COVID-19
“One of the core pieces of population health is really around the data you have to better provide services or better direct resources,” Danielle said. “[With the onset of the COVID-19 pandemic,] we found there were pieces of information we needed to gather pretty quickly.”
Like many organizations, companies focusing on population health had to adjust — and adjust fast — to maintain the consistency of care they provide.
“Many of the people we serve are already homebound, and caregivers already deal with isolation,” Cheryl said.
Chronic conditions, housing and food instability, and the risk of burden, burnout, and strain didn’t go away with the pandemic but, in most cases, were exacerbated. Organizations working in population health had an onslaught of unknown variables to now identify and manage.
To better understand the populations Hennepin Healthcare serves, the health system started with a survey. The focus was on those who are most vulnerable to COVID-19 and whether they could maintain access to basic needs, like food, during the shutdown. It also asked a number of questions related to technology — do they have access, are they able to use it, are they interested in learning and using it more — all to understand where and how to prioritize care first.
Seniorlink took a similar approach. As an entity that primarily serves the Medicaid population, it started by identifying those most at-risk, whether the risks existed before the pandemic or were brought on by it, to ensure Seniorlink could better serve its population’s needs and meet them where they are. Understanding technology use was also critical to be able to pivot quickly from in-person to a remote model.
For Nina and Delta Dental of Minnesota, the challenge was slightly different.
“We don’t have immediate patient interactions,” Nina said. “And at the start of the pandemic, dentists weren’t considered essential healthcare workers,” shared Nina.
Nina and her organization had to focus their initial efforts on supporting their dental workforce and educating their population on how to get them back into the office safely.
“Dentistry changed tremendously,” Nina emphasized. “Tele-dentistry has been around, but not many wanted to use it as a form of care. We started supporting that, especially for emergencies, and I think that’s here to stay.”
Technology, whether it’s telemedicine, artificial intelligence, or increased intentionality with data, took a central role — and will continue to — in reaching populations, understanding them, and providing the care they truly need.
Valuing the Role of Caregivers
One of the most influential changes, beyond technology, has been expanding the focus of care from solely the individual patient to the patient and their support system.
Danielle acknowledges that as a doctor, she only sees so much of a patient.
“Having a group of support around the patient really helps health systems understand them, what’s going on in their lives and their needs,” Danielle said. “We can then think about strategies on how we engage the care support systems in the ongoing care of the patient and how we can get additional insights.”
Much of caregivers’ work has been invisible, unrecognized, and unacknowledged in the broader healthcare landscape.
“When you start to think about how the role of caregiver, the support they offer and the impact they can have in terms of the quality of care and helping to keep their loved ones supported and healthy, it’s really overwhelming,” Cheryl said. “That’s only increasing as we start to look forward with COVID and the sandwich generation.”
Many people are balancing caring for their children and caring for their parents on top of the increased pressures of the pandemic. Their role — whether it’s laying out the correct medications at the right time, managing the effects of chronic conditions, helping with everyday life activities like getting dressed — all contribute to keeping the person healthy and out of the emergency room.
“One of the key things is the caregivers getting an education about oral health and recognizing oral health is key to overall health,” Nina expressed. “One of the last things you think about when starting to take care of a loved one is brushing their teeth every day. It sometimes falls through the cracks.”
Many education opportunities pop up with the expanded focus of care to encompass the patient and their support system. Organizations can take the opportunity to educate caregivers, and care support systems have the opportunity to educate health organizations, all for the betterment of health.
“It’s exciting to me to expand the health interview to acknowledge and include the caregiver and the impact they have on the person they’re serving,” Cheryl said.
Measuring and Sharing Data for Outcomes
It’s no secret that the U.S. healthcare system is rife with challenges. But the task of reconstructing it is met with vigor. Armed with an eyes-wide-open approach and a deeper comfort level with advanced technology makes for a transformational rebuilding of processes.
It helps to avoid constructing new siloes as old ones are broken down. It helps share information in real-time to facilitate care appropriately, plus it helps involve more people at the most effective points of the care spectrum.
“One of the interesting things about data-sharing has been decreasing the barriers between organizations,” Danielle said. “And not just healthcare organizations, but others supporting our patients in the community, whether it be case management or on food security or other things like that.”
When healthcare organizations know how to leave space for someone to identify as not having a consistent food source, for instance, they’re better able to address immediate needs and get the individual connected to a longer-term resource. This kind of community involvement and activation is more difficult with siloed practices.
“If you don’t share data, then getting the clinical outcomes you desire is more challenging,” Nina said.
“One of the complexities, when we talk about outcomes and measurement, are the various tools we are often encouraged or required to report on,” Danielle said. “There are different sets of metrics depending on which lens you’re coming from.”
A health system may word a performance indicator one way, and a community-based organization may frame it differently. The initiatives may be related but evoke different tactics to get to the desired outcome.
The key is finding common ground.
“Think about a baseline,” Danielle said. “And then who needs to be involved.”
From there, sharing data and finding ways to work together, regardless of organization or role, can elevate a population’s health.
Envisioning a Healthier Future
The future of population health is a collaborative, outcomes-first approach powered by data, technology, and people. Payer and provider partners are finding new models that support caregivers. Digital dentistry and artificial intelligence will continue to evolve and mature. Organizations will continue to find new, smarter ways to integrate data systems.
No matter where you fit into the population health puzzle, you have a unique and influential part to play.
To learn more about improving and measuring population health, the effects of COVID, the role of data, and more, check out the full roundtable discussion on-demand.
Tune-in here: Eyes on Population Health Relevant Health Roundtable