Skip to main content

Identifying social factors in managing population health

February 4, 2020

Managing Population HealthPopulation health encompasses the entire spectrum of patient care, connecting traditional clinical with mental healthcare, community services and wellness companies for patients struggling with housing, food and personal safety issues. In addition, as well as possibly contributing to their health problems. Population health is sometimes used interchangeably with but differs from public health in the scope and patterns for policies affecting healthcare, but the goals and processes are similar:

  • Offer value-based care focused on the individual
  • Creative usage of technology and other approaches including remote patient monitoring as well as hands-on services for families undergoing life transitions or needing help with access to nutritious meals
  • Utilize data analytics to sift through and identify structured and unstructured data, such as claims, general consumer data and environmental history and related factors
  • Regulatory compliance from all sources

Population health involves organizations, such as those listed above, coming together to improve the various determinants of health with the goal of improving health and wellness for groups of people, such as the elderly or families with young children. Public health is broader, seeking to protect everyone’s health and reduced mortality through education, public policy, legislation, and social change.

Technology and AI solutions to connecting organizations:

Kaiser Permanente Thrive Local initiative, aided by healthcare IT network Unite Us is an ambitious program to connect its more than 12.3 million members to community and other resources to work toward solving the problems of underserved, disadvantaged people in need of healthcare.  The program’s first phase began in the summer of 2019, with a target of three years for all the communities under its care to participate in the Thrive Local platform.

Using dedicated healthcare IT networks, organizations such as Kaiser Permanente in its Thrive Local program, are better able to link healthcare providers with community organizations for a seamless platform connecting all participating organizations.

Underscoring the critical needs are findings that in some communities served by the program, one third of their people are struggling with food security and housing instability, which in turn seriously affects not only clinical outcomes but all aspects of mental health and family life throughout communities.  Through the new platforms and other tools, electronic health record data will be integrated into health records to offer more intuitive access to information about factors affecting communities at the point of care.

Social factors in managing population health
Critical to the success of these initiatives is the study of social determinants, with the focus being on access to food and affordable housing.

  • Access to housing is a major focus of the Thrive Local initiative which strives to improve not only members’ health but that of the communities as well, by connecting those communities with vital services they need. Homelessness is especially important to Kaiser, having created two additional initiatives to combat this problem in California. Over the next three years, Kaiser, in tandem with their partner the non-profit Community Solutions, will be working to increase housing availability and stability across multiple states, including California, Hawaii, Virginia, Maryland, Georgia and Colorado, for a total of 15 targeted communities for economically as well as socially vulnerable residents.
  • Food insecurity and its impact on health, especially for diabetic patients, is becoming a concern of organizations such as the Blue Cross Blue Shield (BCBS) Institute and Health Care Services Corporation (HCSC). These two organizations partnered back in February 2019 to launch food delivery services for those living in what are commonly termed “food deserts”: areas where there is reduced or no access to fresh produce, meat or nutritious food from full-service grocery stores.  The primary goals of the program is to meet people where they live in order to offer access to affordable nutritious food sources as well as education to making better food and health choices, reducing disparities in healthcare while improving overall quality of lives.
  • Additional social determinant factors include the availability of transportation, proximity to quality healthcare facilities, area crime rates, exposure to environmental pollution and other toxins, employment availability, wages and educational opportunities. Besides Kaiser, Community Solutions and BCBS, organizations promoting improved community and public health include Humana, Aetna, and United Healthcare which have invested hundreds of millions of dollars into initiatives focusing on communities’ food security, housing, healthcare availability and other factors. 

Having a better, more complete understanding of social determinants helps providers offer more effective care, especially for higher risk patients, while identifying potential obstacles that may affect other patients from similar circumstances.

The final word here is from Imelda Dacones, MD, president and CEO of Northwest Permanente believes that “Health care in this country must continue to evolve from acute episodic care to an integrated and coordinated system focused on prevention and coordinated care management.”

To summarize, providers’ records adhering to a value-centric holistic view of patients should include not only the usual clinical data but behavioral information, such as adherence to medications or other parts of a care plan and positive attitude toward treatment.  Physical environment needs to be noted, including type of housing, quality of air or water, access to transportation, and availability of nearby grocery stores or other reliable food sources.

Medical billing solutions to better population health care

Working with a trusted medical billing and practice management service is an excellent way, especially for smaller and/ or independent practices, to offer optimum care to patients from all spectrums of society. Technology is a wonderful tool for staying connected but do you have access to the latest, most efficient billing software and other cloud data technologies, as well as the staff trained and dedicated to ensuring that your claims are sent out completely and correctly, the first time?
As part of your move toward value-based care, making M-Scribe a trusted partner can help you keep your EHR and analytics confidential yet accessible while fully compliant on the path to value-based care for everyone. Contact us at 770-666-0470 or by email for a confidential complimentary analysis of your practice’s billing needs and revenue goals.


Get the Latest RCM News Delivered

Receive practical tips on medical billing and breaking news on RCM in your inbox.

Get in Touch