Value-Based Care

Community Population Health Improvement: Lessons Learned in Real Time

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Jason Gilder, PhD is the Senior Director of Analytics & Informatics at IBM Watson Health

I recently completed a three-week adventure with the IBM Health Corps team in Durham, NC. IBM Health Corps is a global service-learning program focused on tackling health disparities, partnering with health organizations across the world and contributing the time and expertise of teams of IBMers for three weeks on site. My team partnered with Duke Health to build out a strategy to improve the health of the community, with the community. That last piece is crucial to building the trust of the community members and the many organizations already working hard to deliver healthcare and health-related services across the community. We met with several community organizations that are directly involved with delivering health services, referring individuals to health service providers, care management services (assisting patients with managing their mental health visits), providing ancillary services (medication assistance getting access to affordable medications), providing goods related to wellness (cell phones to stay in touch with a care manager or diapers for new mothers), and educational services to keep the public informed (HIV awareness and prevention).

With so much effort across the community, why is population health improvement such a challenge? Why does Durham County lag on certain health outcomes, even with Duke Health, a major healthcare system, in its backyard? Clearly, many organizations are working to address the population’s needs. These same groups will also be the first to lay out the challenges of delivering care in the community. As with many issues in healthcare, it usually comes down to people, process, and politics.

  • Awareness
    Sometimes the biggest challenge in addressing an individual’s need is simply finding the organization or program that can best help him or her. Groups like the United Way supported 2-1-1  program and the Durham Network of Care work to catalog the many organizations, programs, and services that exist in the community. However, the task is an ongoing investment. Organizations change addresses and phone numbers, organizations close their doors, and new organizations and programs are created on a regular basis.
  • Transparency
    Many community organizations are not fully aware of what other organizations are doing. Even when one organization is aware of another, they typically aren’t fully aware of the other organization’s capabilities or quality. This lack of visibility or understanding can lead to uncertainty and distrust and prevent individuals from being referred to those organizations and services.
  • Competition
    Funding is typically the primary challenge of most community-based organizations. Grants are limited and the needs are great. Community organizations often compete for the same funding. Organizations can further compete by offering the same services as one another, presenting competitive messaging about their services, and using a similar approach of recruiting patients for services – all which must be differentiated to help justify their next round of grant funding.
  • Visibility
    Successful population health improvement efforts require the right information at the right time. However, information sharing rarely takes place between organizations. An organization dealing with diabetes management may not be aware of an individual’s ability to obtain nutritious food. A patient seen in the hospital may not offer information about his housing environment and ability to care for himself after discharge. The disconnect can result in siloed care efforts where no single organization possesses a complete view of the patient’s condition and social determinants of health.

None of the challenges listed above mentioned a broken system, only one that can be improved with better coordination and collaboration.

  • Coordination across services
    Individuals in need typically require multiple services. Organizations that are tightly coordinated can track referrals to ensure that an individual is enrolled in the program he or she needs. A patient in the hospital who has an issue with adequate housing can be referred to the right affordable housing program. The patient’s care manager can be informed when the patient has been enrolled and placed in a better home.
  • Collaboration around programs
    Most community organizations have established goals for their own programs. However, community population health improvement efforts would likely be more successful if care management programs were jointly created across multiple organizations. Tackling diabetes and nutrition could involve a diabetes management group and a food access organization building out a common care program together.
  • Collaboration around funding
    Collaboration across organizations extends beyond joint programs. Opportunities exist for organizations to work together on joint grant opportunities. Consider this – a program may appear to be losing money in one area while driving overall savings around an individual’s care. Funding for such programs is often cut. Collaboration across organizations will allow for better tracking of overall program effectiveness, return on investment, and opportunities for better funding. Funding is the biggest need for these organizations.
  • Collaboration around staffing
    Typically, the second biggest need of an organization is adequate staffing. There are opportunities for organizations to partner around sharing resources. Individuals working in one organization can work in a partner organization as a “borrowed resource” when demand is high or when a specialized resource is needed, such as a mental health professional.
  • Collaboration around data sharing
    Understanding the full view of individuals and their outcomes is often improved by sharing information between organizations. While legal and compliance hurdles can be problematic, they are not impossible. Proper data use agreements and business associate agreements often allow for data sharing to enable more complete patient management.
  • Collaboration around measuring outcomes
    Understanding true outcomes for a population is greatly enhanced with the collaboration of multiple organizations. Joint quality metrics across organizations can help track the population’s journey through the system to understand which areas are working and which need additional focus. That feedback loop is essential to improving our system of care.
  • Collaboration with the community
    Population health improvement efforts require the community’s active participation to be successful. The best way of getting community investment is through transparency and feedback. It should be clear what services are being offered, how quality is being measured, and what impact is being observed in the community. Community members should have an opportunity to play a role in shaping the programs and goals to ensure that the overall needs are being met.

These combined health improvement efforts introduce the opportunity to address true community population health. Once you understand the state of health of a community, you can introduce additional programs on social determinants of health to help drive community-based health improvement at a larger scale. Leveraging additional data sources, such as bus routes, bike trails, pollution levels, socioeconomic status, food pantries, parks, and program benefit coverage areas allow for a macro view of the community. This view then allows for more effective planning around what programs, services, and opportunities should exist for individuals and where they will make the greatest impact on the community. The future blueprint of the community forms a community health care plan and can be tracked and managed in a similar manner as traditional population health programs. A community care management program can establish quality metrics to track process and outcome metrics across neighborhoods to understand which areas are improving and which require greater focus and attention.

In the long term, cognitive technologies could play a big role in community health management and improvement.  The data being captured by community based organizations is often wildly varied in its form and content, including raw metrics and results, surveys, and unstructured text and reports.  Cognitive technologies offer the ability to read, understand, and normalize the data across all of these forms.  The result will be the ability to view a community holistically to identify needs, determine the efficiency of programs, and track outcomes.

In the short term, none of the opportunities here requires a drastic redesign of the care delivery system or millions of dollars in infrastructure or software. However, it does take a concerted effort to align priorities and involvement across care delivery stakeholders, community partners, and the citizens themselves. Many components of these improvement efforts are already underway in Durham County and elsewhere across the U.S. It is important to identify which pockets of activity are working well to serve as a guide for others moving forward. Population health improvement does not need to be a big bang. Improvement efforts can be rolled out in phases to increase trust and collaboration across a community over time. However, it is crucial to continually maintain, expand, and refine improvement efforts so that health delivery stakeholders and the community remain engaged in the process and to ensure that the momentum of driving improved health outcomes is not lost.

For more on this topic, register for the upcoming webinar “Redefining Population Health” where I will be joined by Pam Maxson, Ph.D., Director of Operations at the Duke Center for Community and Population Health Improvement and Marissa Mortiboy, MPH, Program Coordinator at the Durham County Department of Health.

During this presentation, we will cover:

  • The Partnership for a Healthy Durham and creating a “culture of health”
  • The work being done at the Duke Center for Community and Population Health Improvement
  • IBM’s Health Corps engagement in Durham, including aligning cross-sector stakeholders and considering social determinants of health

Senior Director of Analytics & Informatics at IBM Watson Health

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