The social determinates of health may outweigh the impact of clinical care, but how can providers create community-based population health management partnerships?

A successful population health management program must be built on strong, engaging, and collaborative community partnerships in order to tackle the social determinates of health for needy patients, says a new report by the Advisory Board Company.

As the healthcare industry starts to develop holistic patient management strategies based on the idea that clinical care accounts for only a fraction of ultimate outcomes, healthcare organizations should seek out social service organizations, public health officials, and complementary provider services to create a robust social safety net for patients.

“Health care extends well beyond care settings—into homes, schools, and neighborhoods,” said Rebecca Tyrrell, Senior Consultant, Research at Advisory Board.

“Hospitals and health systems can improve community health by addressing the nonclinical factors that influence health in their neighborhoods, since partnerships with community organizations can address the upstream causes of poor health.”

The report, called “Building the Business Case for Community Partnership,” outlines several best practices and suggestions gleaned from the successes of the BUILD Health Challenge, a multi-stakeholder effort to architect “bold, upstream, integrated, local and data-driven community health interventions” for communities across the country.

“Partnerships among health systems, public health bodies, and community organizations are the most effective ways to address community health,” Tyrrell said.

“In many communities, hospitals, local not-for-profit organizations, and health departments are pursuing the same objectives but have not coordinated to share valuable data, information, and resources.”

The BUILD framework, initiated in eighteen communities across fourteen states, aims to address this fragmentation by giving providers and social service groups the tools and funding they need to forge meaningful population health management coalitions.

In order to focus on high-priority social determinates of health, including food insecurity, utility and housing instability, interpersonal violence, lack of transportation, and health literacy, providers should follow a four-step plan for successful, community-based population health management.

Secure executive and leadership buy-in by developing a strong business case

Executive buy-in the key first step for so many healthcare initiatives, and population health management is no exception.  Helping organizational leadership understand the deeply-rooted problems of unmet social needs – and presenting a comprehensive, detailed plan for how resources will be used to achieve a return on investment – is critical for getting the C-suite nod.

One of the overall goals of population health management is to lower costs for providers, patients, and the health system as a whole by delivering preventive care and forestalling the development of expensive chronic diseases.

Increased access to primary care is one promising avenue for achieving these results, but patients who cannot make appointments, keep appointments, or engage in self-care according to provider recommendations can stall population health efforts.

Access to transportation, stable and safe housing, and healthy dietary choices are three social determinates that can reduce missed or rescheduled appointments, slash emergency department use, and ensure more consistent contact with the healthcare continuum, the report says – all of which contribute to savings.

Organizations looking to convince leaders that community-based population health can cut spending should take a data-driven approach to building their business case.  In addition to clinical outcomes and utilization data, they may wish to choose additional metrics to gauge the success of downstream population health efforts, such as:

  • Percentage of patients in regular contact with a primary care provider or medical home
  • Hospital admissions or ED use per 1000 patients
  • Percentage of no-show appointments or appointments rescheduled multiple times
  • Prevalence of specific chronic diseases, such as diabetes, obesity, or COPD
  • Overall per member per month cost of care
  • Patient satisfaction and experience scores, including personal health ratings and confidence in health literacy
  • Rates of exercise, healthy food choices, tobacco use or alcohol use

Presenting a plan with clear, well-defined goals that are directly tied to potential cost savings may be an important factor for securing initial investment from organizational leaders and guiding implementation efforts.

Choose a high-priority test case to develop best practices for future use

Starting small with a well-defined test case can help organizations understand the hidden challenges and unforeseen obstacles of population health management.  A narrow focus can also prevent “decision paralysis,” the report says, and reduces the likelihood that resources will be stretched too far to make a measurable impact for patients.

Forty-one percent of BUILD project participants chose to focus first on issues of nutrition and food security, since dietary choices are linked to a number of common, costly chronic diseases.

Programs such as a hospital-owned grocery store offering healthy options, a community garden, nutrition and cooking classes, and free or discounted meal services helped to connect patients with nutritious offerings and financial assistance.

At Boston Medical Center, a food bank helps approximately 7000 people per month with food insecurity issues while paying special attention to the perceived stigma of accessing the supplemental resource.  Users have access to translation services to prevent misunderstandings, and are encouraged to use discreet packaging, such as unlabeled bags or suitcases, to carry their food home in order to avoid discomfort, or can have a family member pick up the items for them.

Programs that address food insecurity may help to reduce poor overall health status, which is nearly three times as likely in food-insecure households, the report states.

Providers are advised to use a combination of clinical data, community stakeholder input, patient demographics, and feedback from front-line staff to identify promising use cases that will meet social needs while producing measurable ROI for providers.

Reach out to community organizations to launch meaningful partnerships

Once an organization has decided on its initial test case, it can begin to reach out to partners within the community who can strengthen the ability to deliver value to patients.  These potential partners should have similar objectives in mind.

“However, shared goals do not ensure a seamless working relationship,” the report warns. “Formalizing partnerships with these groups extends reach while building on the skillsets, relationships, data, or tools each partner brings to the table.”

Healthcare providers participating in the BUILD initiative commonly partnered with local school districts and universities, public health departments, faith-based groups, service leagues, non-profits, and public safety organizations.

Building trust between stakeholders is vitally important for success, and should start with a two-way discussion.  Provider representatives should be actively involved in community meetings, and should stay open-minded while doing so, especially when needs identified in the community may be different than those flagged by providers themselves.

A cooperative approach will help ensure that providers are able to work with community organizers instead of attempting to impose ideas and strategies on existing initiatives.  A respectful, collaborative attitude can create the positive relationships required to achieve real results.

Specific pieces of advice from BUILD organizations revolve around patience, enthusiasm, and a long-term view of decision-making.  Their suggestions include:

  • Make a commitment to action through leadership and sustained investment in time and resources
  • Be willing to spend a significant amount of time in “listening mode” to gather input and suggestions from the community, find common ground, and give leaders the chance to emerge as natural partners
  • Allocate actionable tasks to smaller teams within the collaborative environment to ensure that items are completed quickly and the community remains agile
  • Ensure that decisions consider the long-term needs and goals of the community, and that tasks remain tightly aligned with the needs of patients and consumers, not the business desires of one particular organizer.

Balancing these imperatives may take practice for healthcare providers and their partners, especially as implementations become larger and engage more stakeholders.

BUILD organizations averaged three primary partners for each project but averaged eight total organizations per initiative, indicating that diplomacy, focus, detailed planning, and open communication are fundamental for success.

Design patient screening and referral protocols to ensure coordination of care

The last step, which is operationalizing patient-facing services, can be one of the most difficult.  While the planning phases require some exchange of ideas and information between collaborators, true community-based care coordination demands interoperability and information sharing every single day for every individual patient.

Many healthcare organizations already have risk stratification strategies in place, which can help to identify patients in need of particular services.  But providers are less adept at communicating this information to outside organizations, ensuring that patients follow up with recommendations, and developing the health IT infrastructure required to accept data about the patient back into the system.

Population health management and risk stratification tools should incorporate non-clinical factors into risk score determinations and should also include socioeconomic, behavioral health, and other community-based data into their algorithms, the report says.

“Assessing both clinical and non-clinical risk factors simultaneously helps reframe social issues as health issues while also helping providers customize interventions,” the authors write.  “A best practice risk assessment tool strikes a balance between being highly predictive of readmissions or poor health outcomes and not overly burdensome for staff to perform.”

Taking a team-based approach to patient management was effective for BUILD participants, who used community resource guides to coordinate social and non-clinical patient services across multiple domains.

Massachusetts General Hospital in Boston built multi-disciplinary teams consisting of a primary care provider, nurse care management, social worker, pharmacist, community resource specialist, and medical director to ensure that high-risk Medicare patients could access clinical care and social services in a coordinated, seamless manner.

The effort, supported by participation in a long-term CMS demonstration program, produced a net care cost savings of 7 percent in the first three years for the top 2500 high-cost Medicare patients while reducing hospitalizations by 20 percent and ED visits by 35 percent.

Ensuring that patients have a clear and accessible point of contact for their needs is an important success factor for care coordination, the report notes, and can create a trusted, collaborative relationship that will allow providers and patients to leverage existing resources, create new healthy habits, and achieve better outcomes over time.