Managing complex and chronic disease is complicated, and for some patients, there are numerous factors which can make the task especially difficult and therefore, seemingly impossible. The health care industry has relied for far too long on the episodic approach to care, i.e. a patient walks into a provider’s office, receives a diagnosis of chronic disease, is given medication and instructions, and is then assumed to have the tools they need to manage their new disease (and its impact on their life) successfully for at least the next three months when they see their provider again (again, assuming they will see this same provider in the advised time frame).

Episodic care is an unrealistic and ineffective approach for educating patients about their chronic condition, jeopardizing their activation in managing their disease, and reducing the likelihood of positive health outcomes. Particularly so for high-risk patients who face unique life circumstances and heavy social barriers, which greatly impact their ability to access health care.

Managing complex and chronic disease is complicated, and for some patients, there are numerous factors which can make the task especially difficult and therefore, seemingly impossible. The health care industry has relied for far too long on the episodic approach to care, i.e. a patient walks into a provider’s office, receives a diagnosis of chronic disease, is given medication and instructions, and is then assumed to have the tools they need to manage their new disease (and its impact on their life) successfully for at least the next three months when they see their provider again (again, assuming they will see this same provider in the advised time frame).

Episodic care is an unrealistic and ineffective approach for educating patients about their chronic condition, jeopardizing their activation in managing their disease, and reducing the likelihood of positive health outcomes. Particularly so for high-risk patients who face unique life circumstances and heavy social barriers, which greatly impact their ability to access health care.

Population health aims to overcome these obstacles by looking at the holistic picture of health for specific groups and tailoring an approach to care which ensures that their health needs are being met and patient outcomes improved. According to HIMSS, population health “brings significant health concerns into focus and addresses ways in which communities, healthcare providers, and public health organizations can allocate resources to overcome the problems that drive poor health conditions in the population.”

Yet, as we know, even with this bigger picture approach, the most at-risk patients continue to face significant obstacles to care, as do the caregivers aiming to help them. The full picture of patient health includes the determinants which keep care beyond reach and often exacerbates health issues. As more insight is gained as to how population health efforts can best support patients in achieving healthy outcomes, it’s become clear that social determinants of health must be identified, tracked, and addressed in order to mitigate obstacles to care and help those most in need.

Barriers to care

Social determinants of health play a huge role in the health outcomes of certain patient populations. According to Centers for Care Innovations, “social determinants (health-related behaviors, socioeconomic factors, and environmental factors) account for up to 80 percent of health outcomes…” as a result, “there is also a need to broaden the population health management lens to include understanding the social, political, and cultural context in which patients and their families live and to focus on providing whole-person care.”

A person diagnosed with type 2 diabetes who has a car, good health insurance, a flexible job, steady income, childcare, and access to healthy foods is not going to run into the same obstacles accessing care and managing their health as a person newly diagnosed who is without one or more of those advantages. Factor in comorbidities and additional challenges such as homelessness or mental illness and the problem gets bigger.

John W. Robitscher, National Association of Chronic Disease Directors (NACDD) CEO explains, “How do we make sure that every person has a safe place to live, clean food, and water? How do we make sure they have transportation to and from medical attention whenever they need it? It does take a village to take care of people.”

Humana is making an effort to improve population health with their Bold Goal program which focuses on “identifying and addressing social determinants of health to boost outcomes for Medicare beneficiaries in communities across the country.” The program uses the Centers for Disease Control and Prevention (CDC) population health tool called “Healthy Days” which factors in an individual’s physical and mental health over a 30 day period. Using the tool, Humana can “determine key social determinants of health, including food insecurity, loneliness, and social isolation. The tool has also helped Humana identify specific groups in need, such as seniors and lower-income adults,” reported HealthITAnalytics.

While programs like Bold Goal are poised to make a big impact, it’s critical that patients also be actively involved in managing their own health. Patients need to understand their health condition and how to care for it, have longitudinal relationships with their providers and care teams, and be able to access any kind of support services that will help them accomplish all of this. Patients dealing with complex disease usually require care from multiple sources. Not just for their physical comorbidities, but also for mental health. Researchers have found many associations that exist between mental illness and certain chronic diseases—depression is found to co-occur in 17% of cardiovascular cases, 23% of cerebrovascular cases, and with 27% of diabetes patients. Therefore it’s also vital that providers and care teams communicate effectively across specialties, working together to achieve a singular goal—healthy patient outcomes.

Technology can be an advantage for population health management, aligning all providers and case managers, supporting patients, and establishing a continuum of care that will improve health outcomes for even the highest risk patient populations.

How technology can strengthen population health

Technology can play a big role in improving population health management by creating  customized patient experiences which effectively support patients across populations, while addressing individual patient needs. The ability to identify and track the social determinants that create barriers to care for patients is essential in order to understand the impact on their health and devise effective solutions.

An integrated platform can identify those risk factors, trends, and other important data that may be impacting patients and prohibiting them from accessing the care they need aggregated in one location where every provider across their continuum of care can reach. When care teams have data insights from patient populations and can identify the factors that pose the greatest risk to patients, they can intervene before they have a long term, irreparable impact on the patient’s health.

Community Health Center Network (CHCN) is a great example of this. CHCN was partnered with Welkin through an initiative sponsored by Health 2.0’s Technology for Health Communities to build a case management software for CHCN, designed specifically for patient support to meet the needs of their Care Neighborhood program. Programs like Care Neighborhood that close gaps in care and work to eradicate the social determinants which prevent patients from accessing care in the first place, also help to reduce the significant health care costs that are accrued from frequent trips to the ER and avoidable repeat hospitalizations. Care Neighborhood has shown great improvements in these areas with 43 percent fewer inpatient admissions, 21 percent reduction in ER visits, and 32 percent increase in PCP visits.

There is no magic wand we can wave to reduce the disparities that so many populations face when it comes to accessing effective and consistent health care. However, as the scope of population health continues to grow to include every facet impacting patient health, technology that can be leveraged to identify these factors and confront them will help providers better support at-risk patients to become highly activated in managing their own health, yielding better outcomes for everyone.