Home Health Care The paradox of population health: Focus on personalized support for the greatest...

The paradox of population health: Focus on personalized support for the greatest impact


Abraham Maslow said in 1966, “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” This mentality — known as the Law of the Instrument — indicates that people tend to rely on the tool with which they are most familiar.

In a healthcare setting, that can translate into only using traditionally trained medical professionals to handle every situation, but in reality, some issues require a collaborative approach that includes other skills and experience. This is particularly relevant when it comes to addressing social determinants of health (SDoH).

Social determinants of health can include many things: food, housing and transportation insecurities; lifestyles, locations and surroundings; social isolation; and other factors that prevent people from achieving and maintaining good health. Non-clinical influences like these can drive up to 80% of clinical outcomes, affecting an individual’s ability to be healthy.

In other words, it takes more than the latest treatments to keep people healthy. Much work is being done to address social determinants at the public health level, but these factors must also be addressed at the patient level. The paradox about “population” health is that it’s all about individuals — and using a collaborative approach can be the key to success.

Why the Collaborative Approach Works
Studies indicate that patients who perceive their providers as more empathetic tend to get better more quickly, and experience less severe symptoms. Yet providers sometimes lack the capacity to treat patients holistically, or the data and insights to understand why a patient isn’t taking their medicine, even though insights into social barriers can guide how providers should interact with patients.

Educating a patient is helpful, but typically not effective at changing behavior, especially when social factors are at work. Additionally, people trained in the medical field are not also trained and resourced to deliver interventions involving social factors.

This is where an interdisciplinary team approach can help to improve population health by addressing social determinants at the individual level. The best approach to care involves a team that includes a range of medical professionals, social workers, behavioral health specialists and community health coaches, all working together to formulate and deliver a comprehensive support plan tailored to each patient’s priorities and needs.

Instead of telling patients what to do, local care teams can work with patients to understand their barriers, such as lack of transportation or housing insecurity, and tap local resources to reduce or remove them. By simply asking the right questions, community health coaches can get much more tactical and concrete about supporting the individual and tailoring treatment support plans.

Additionally, these coaches often live in the same community and understand the context of people’s lives, which improves communication and creates trust. In fact, Medicaid members who receive community-based services are less likely to be admitted to the ER or as an inpatient in a hospital. During one-on-one interactions, community health specialists are well-positioned to understand the social roadblocks to access care and adhering to treatment plans.

A collaborative team is ideally suited to assess the social and environmental factors impacting a person’s health, identify barriers of care, and create a personalized support plan that may include services such as behavioral health support, patient advocacy, and remote monitoring technology to remove those barriers and improve care plan adherence.

The Four Components of Success
A successful strategy to address social determinants of health comprises four components:

Analytics: In any population health intervention, the team needs to identify through stratification who is at the greatest risk, to properly titrate the resource intensiveness of an intervention. If you try to intervene equally with everyone, your efforts (and funds) will be spread too wide and too thinly.

Using analytics on the front end can ensure that the people with the highest risk are receiving more intensive treatments. Healthcare teams can look to existing data sets like consumer marketing data, which often is a treasure trove of information on factors that affect health such as transportation, housing issues and financial stress. For example, data can reveal if an individual lives alone, owns a car, or lives near public transportation – all factors that impact a person’s ability to follow through with their care plan. These insights can be integrated with data on medical risk and cost of care before the amalgamated data set is stratified.

A multidisciplinary support team: As stated, for social determinants to be addressed on an individual level requires an integrated team of both clinical and social support experts and community-based coaches are essential contributors.

The right toolbox from which to draw: There are existing toolboxes of interventions for housing, food insecurity and stress management, and the care team should recognize what needs to be addressed and draw from existing strategies to address healthcare at the social level. Interventions that mitigate the social stressors impacting an individual around the clock provide the greatest health benefits.

Respect for the individual’s priorities: A population health team must have the flexibility to prioritize what the individual sees as the greatest issue. For example, a homeless individual might have a substance use disorder (SUD). Typically, people with SUD cannot get into housing until they are in recovery; however, if the individual is not ready to work on their recovery, but does see stable housing as a stepping stone toward recovery, that should be respected — so work first on what they’re ready to work on.

A Better Approach to Addressing Population Health
While the use of multidisciplinary teams can involve significant changes to work practices and organizational arrangements, providing community-based resources is essential to addressing social barriers that affect health and wellness.

By understanding the social factors that can impact patient wellness, and employing a collaborative approach to individual care, payers, providers and patients will reap the benefits of more successful outcomes — improving population health overall.

Photo: marchmeena29, Getty Images

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