Improve Patient Engagement with Five Public Health-Inspired Principles

patient-engagement-public-healthAs the payment landscape evolves and financial responsibility for outcomes shifts to provider organizations, getting patients to make good choices where it comes to their health is a population health imperative. The fiscal importance of this work is critical. Even the “seemingly simple” step of taking medication is a huge societal challenge, with non-adherence costing $300 billion annually. Furthermore, this is not only hard work, but often frustrating work. As we move away from episodic payment (or bundled payment), we’re not just encouraging patients to take medications and follow discharge instructions, but insisting they exercise, eat better, and smoke less. How many times have you heard a clinician ask, “How can I be responsible for outcomes when I have no way to control what my patient does at home?”

A Better Approach to Patient Engagement

First, a definition of patient engagement from Health Affairs:

“’Patient activation’ refers to a patient’s knowledge, skills, ability, and willingness to manage his or her own health and care. ‘Patient engagement’ is a broader concept that combines patient activation with interventions designed to increase activation and promote positive patient behavior, such as obtaining preventive care or exercising regularly.”

Avoid Asking Patients to Do Too Much

Too many patient engagement initiatives start with the premise that we need to find strategies to get patients to do more; we believe this approach is deeply flawed. While patient engagement will never be an easy task, there is a fundamental flaw in the current approach used by many health systems to approach this work today. The great majority of patient engagement strategies assume individual responsibility, or work by asking the patient to take charge and do more. However, if we look to the field of public health, which has long managed populations of patients, the most effective strategies to improve population health pair behavior change with systematic interventions. For example, while reductions in motor vehicle fatalities are partially due to improved seat belt usage (a behavior change), systematic changes outside the individual’s control, like safer vehicles and roadways, played a larger role. From this point of view, population health managers face a dual challenge: improving strategies for engaging individuals in behavior change, while systematically preventing illness at the population level.

A Population-Focused Approach

Public health teaches us that systematic, population-focused efforts are often more effective than those that target individuals. To underscore the importance of systematic interventions, consider a condition like cholera. Initially, medical opinion concurred with the public: The disease was a judgment from God and those who were “intemperate, imprudent and filthy were predisposed to this most dreadful disease” (source: This helped to explain why Irish immigrants, with their suspicious Catholic faith, as well as African-Americans, and those living in the tenements of major cities were among those hit first and hardest by the disease. Later, the medical community came to accept that filth caused cholera and asked individuals to do their part: Clean yourselves, clean your homes, and clean often. This was also not very effective. It’s easy to see in retrospect that these are hard problems (for individuals) to tackle without clean water and sanitation infrastructure available—in other words, systematic, population-focused interventions.

We rarely compare cholera to chronic conditions like diabetes and heart failure. But when we look at those impacted, there are striking parallels. Chronic conditions—a significant driver of healthcare spending and a tremendous focus in risk-based contracts—disproportionately impact those who are poor, who are minorities, and who live in the least-desirable areas of major cities. Income is a significant predictor of health: Impoverished adults die almost a decade earlier than individuals with incomes four times the federal poverty level (just around $11K annually).  We so often characterize modern health issues as arising from laziness or a failure of willpower, but we believe hindsight will tell a similar story as it has for cholera. While strategies to change individual behavior are valuable, particularly in the near-term, we won’t fully resolve these epidemics until we employ systemic interventions.

What We Can Apply from Public Health

Instead of recreating the wheel on patient engagement, start with public health concepts and ask the question: Which of these are financially viable in today’s payment environment? In a fee-for-service environment, public health and healthcare managers typically had different fundamental goals. With public health thinking about patients over decades, and healthcare organizations focused on a single acute episode or ambulatory visit, there wasn’t a lot of opportunity to share strategies between the fields. However, the advent of new payment models that make health systems responsible for populations of patients over much longer timeframes realigns these fields. Instead of asking how to improve our current patient engagement strategies that were developed in a tradition of treating illness, we should instead be asking which of public health’s strategies are fiscally viable today?

Five public health-inspired patient engagement principles:

If we accept this premise, we can ask the question: What does public health teach us about patient engagement? We’d ask you to consider the following guiding principles as you develop your overarching patient engagement strategy and vet focused interventions:

  1. Look for systematic, population-level solutions that require less individual effort—Taking a page from public health’s Health Impact Pyramid, have you considered strategies that work at the population level in addition to those that are focused on individuals? Often these population level strategies have the added benefit of requiring less individual effort. For example, improving safety or adding a park to a neighborhood might help a whole community get outside and exercise more, instead of individually counseling a small subset.
  1. You will have a more lasting impact by developing a multi-faceted approach that engages the patient on not only the individual but interpersonal and community levels—The socio-ecologic model teaches us that hitting a problem from all angles (the individual, interpersonal, institution, community, and policy level) is likely to be far more effective than just addressing any one. Successes in smoking cessation came not just from individual education alone but strategies like taxes, restaurant bans, and public campaigns that effectually make it not only harder to smoke, but less socially acceptable. As you hone in on key problems in your population, does your strategy include an intervention at multiple levels of this model?
  1. Take the time to identify root-cause, assess and capitalize on strengths, and engage stakeholders; there is not a one-size-fits all approach—Whether designing a population- or individual-level intervention, it is critical to make sure you understand the root cause of the problem. Asking an individual to do something as seemingly simple as weigh themselves daily when they can’t stand steadily on a scale becomes an impossible task. Have you embedded opportunities to engage patients to provide this type of feedback at the individual level? At the population level, have you invested time assessing root-cause, capitalizing on strengths (like local community resources), and engaging stakeholders?
  1. Use strategies from behavioral economics to help individuals make good choices—When it comes to making healthy choices, we are not starting on a level playing field. Behavioral economics shows us that individuals tend to struggle to make good choices. For example, we struggle to weigh costs and benefits that are separated across time, such as a cigarette today versus lung cancer decades from now. Furthermore, whole industries like tobacco and junk food make a lot of money by exploiting this fact. Have you considered how to use strategies learned from behavioral economics, like framing questions differently or resetting defaults, to make it easier to make good health choices?
  1. Anticipate failure and learn from it (data and a quality improvement mindset are key)—Knowing there is no one-size-fits-all approach, build an infrastructure that anticipates failure. How will you use data to measure baselines and monitor success so that you can recognize and scale successes and divert efforts away from programs that don’t work? The quality improvement mindset of plan, do, study, act is highly relevant to this work.

Analytics Are Critical to Patient Engagement

Analytics should play a key role in helping you to not only prioritize key focus areas, but to assess return on investment, help guide improvements, and make the financial case for this work. A well-considered patient engagement strategy not only reflects the principles above, but uses data to ensure that you are focusing your efforts on solving the greatest challenges and employing interventions that give you the greatest bang for your buck.

  • Have you identified the populations that require the greatest support and engagement?
  • As you develop patient engagement strategies for these groups, have you assessed your interventions to determine if they’re financially viable? What’s the likely return on your investment and in what timeframe?
  • If there’s not a return, but the strategy seems like the right thing to do, how can you use data to build the case for getting paid for providing that service?

Aim for Less Individual Effort

If there is a golden rule in these principles, it is this: Always consider opportunities to employ population-focused or systematic interventions that require less individual effort. Think of the patient’s mindshare for engagement as a highly valuable but limited resource; use it wisely.

While we have a tremendous amount to learn as we lay the groundwork for viable population health strategies, we save ourselves a lot of heartache if we stand on the shoulders of giants in the field of public health as we build these new competencies.

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