Population Health Documentary Highlights Three Success Stories Transforming Healthcare

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“Healthcare hotspotting is a data-driven process for the timely identification of extreme patterns in a defined region of the healthcare system. It is used to guide targeted intervention and follow-up to better address patient needs, improve care quality, and reduce cost.”Camden Coalition of Healthcare Providers

Five percent of the U.S. population accounts for 50 percent of the total cost of care. Some of this can be attributed to a population with chronic conditions, which is living under the social stresses of poverty, racism, and inequality. At the same time, our country spends an inordinate amount of money on substandard healthcare burdened by fragmentation, siloing, and lack of access. The healthcare marketplace has considerable uncertainty in light of possible legislative changes, and the list of healthcare’s additional woes is long. Where are the population health success stories?

Population Health Documentary Highlights Three Successful Initiatives

The Health Catalyst® population health documentary, “A Coalition of the Willing: Data-Driven Population Health and Complex Care Innovation in Low-Income Communities,” opens with this bleak picture of the healthcare landscape. It’s the backdrop for cities like Camden, New Jersey, where 95 percent of residents are eligible for Medicaid and where the Camden Coalition of Healthcare Providers is deploying a unique brand of population health to address these burdens.

Serving the Underserved

Since 2002, the Coalition’s partnership of clinicians, caregivers, and healthcare organizations has successfully used hotspotting, as defined above, to focus its care management teams and better understand who in the community can benefit the most from its services. Using data, it pinpoints subsets of patients with complex care needs (those who comprise the five percent), identifies interventions, and then standardizes those interventions to reduce the costs of care. The coalition’s advanced care management program empowers patients and providers to work together, giving everyone a stake in the healthcare system.

Imagine building this into a framework that could be used anywhere, which leads to the second program featured in the documentary.

Preventive Care for an Elderly Population

Health Quality Partners in Doylestown, Pennsylvania has been researching, developing, and deploying advanced preventive care models for the elderly since 2001. And it’s working because the team has reduced mortality among its population by 25 percent. Like Camden, it’s a coalition of doctors, nurses, social workers, outreach specialists, and data analysts that uses hotspotting to identify people who need care the most. It pulls data from the EMR every night and uses it to calculate risk scores on 172,000 people in the system. The team then infiltrates the community to deliver that care. It’s a unique perspective that calls for caregivers who are dedicated to the total context of people’s lives.

Care Management for a Complex System

A third case study featured in the documentary comprises a larger system that delivers care management services to a broad scope of urban and suburban communities. Partners Healthcare serves 80 percent of the residents in the Commonwealth of Massachusetts, which includes 20,000 high-risk patients that require everything from pediatric to geriatric care. Again, a critical element for delivering this complex, wide-ranging care is data. It helps them know who is in their healthcare system, when and where. Data also helps Partners Healthcare track performance so it knows where to focus efforts. And, again, results have been remarkable, with four percent lower mortality among the care management group as compared to a matched comparison group.

Redefining Healthcare

We need to redefine healthcare, so we focus on health across all boundaries, think in new ways about what health is, and prioritize preventive health to keep people out of ERs and hospital beds. This is the idea behind population health, but it needs to overcome the predominant fee-for-service mindset that exists in healthcare today.

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

  1. No More Excuses: We Need Disruptive Innovation in Healthcare Now
  2. A Guide to Care Management: Five Competencies Every Health System Must Have
  3. The 3 Must-Have Qualities of a Care Management System
  4. The Great Equation in Healthcare is Wrong
  5. The Rising Healthcare Revolution: The Future Is Already Here
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