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Predicting Patients’ Next Healthcare Moves: How HIT Stakeholders are Keying in on Advanced Population Health Management

July 28, 2017
by Rajiv Leventhal
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An example of the tool being put in use, explains Mishra, would be a Northwell patient navigator who is in charge of patient outreach, reaching out to people in the Home Health population. In this scenario, the Care Tool will show the patients linked to that program, and once the navigator sees that, he or she can then see who the outliers are (the non-compli­ant patients), who might need appointment remind­ers, or who has been discharged within the last seven days. Those patients will then be pursued to see their primary care physician (PCP) if necessary, or a similar action will be taken, Mishra says, adding that a clini­cal snapshot in the EHR also gets sent from the Care Tool to the PCP, who can take a quick look to see if vaccines or immunizations are missing. The real-time alerts and ability to risk stratify in order to identify high-risk patients are all triggered by what’s originally entered into the tool, Mishra notes.

Meanwhile, Northwell’s DSRIP work creates broader population health challenges, since the state mandates that every physician practice associated with the pro­gram has to have an EHR by 2018, something that some of the health system’s voluntary practices still lack. Also, the practices have to all be Level 3 PCMH (patient-cen­tered medical home), meaning having the ability to col­lect and use data for population health management, as designated by the NCQA (National Committee for Quality Assurance). Like with the EHR mandate, North­well is also currently short of this requirement. Says Mishra, “We are still working towards DSRIP’s goal of 25 percent reduced [avoidable hospital] readmissions over a period of five years. The grant, which I wrote along with other folks on my team, was [based on] proving to the state that your health system was already invested in doing population health management. So you show them that you would have used the health system’s money to invest in population health,” she says. “It’s a lot of contracting and negotiating. Plenty of work is still ahead of us.”


Most experts would agree that although efforts to im­prove healthcare in the U.S. have largely been focused on the clinical side, it would be unwise to ignore the many social, economic, and environmental factors that influence a person’s health.

At Humana, the Louisville, Ky.-based health insurer, a “Bold Goal” program was put into place two years ago with an overarching aim to make the communities it serves 20 percent healthier by 2020. For this goal to be achieved, it’s necessary to understand that social deter­minants of health are fundamentally important in terms of how to care for populations, says Roy Beveridge, M.D., chief medical officer at Humana. He notes an ex­ample of a diabetic patient being food insecure; the likelihood that this patient will have a prescribed diet and can control his or her sugar intake is quite small. “In the U.S., we have 5.4 million seniors who are food insecure, and if you don’t address that issue, treating someone’s diabetes—meaning also taking care of blind­ness, diabetic foot ulcers, and kidney disease—becomes very hard. But we do know that by working with grocery stores, hospitals, the local government and others in the community, you can begin to take care of food insecu­rity,” Beveridge says.

However, despite a growing recognition that looking at these social determinants of health is a critical com­ponent of improving one’s care, just four or five years ago, most physicians would have said that it’s a social worker’s problem rather than a clinical issue, says Bev­eridge. “This is why the move from fee-for-service to val­ue-based care has begun to focus in on [the notion] that treatment is more than giving someone a prescription. Fundamentally, how can I influence this person’s health as opposed to giving him or her a medication and then saying the patient is non-compliant?” he asks.

Drilling down deeper, Vipin Gopal, enterprise vice presi­dent, clinical analytics at Hu­mana, notes the importance of integrating the internal Hu­mana data that the payer has on its members with the data it has about its communities, and with the social determi­nant data. “That gives us a broader view about the health of a community that we didn’t have by just looking at primary claims from a payer perspective,” Gopal says. What’s more, he notes, understanding the given population in detail is also critical. “What would lead a person to progress from their diabetes condition into getting ad­ditional complexities, be it congestive heart failure or something else?” he asks. “It helps us move things from a population perspective and enables us to be more personalized in the solutions we offer to our members.”

Vipin Gopal

To this end, one of the biggest challenges in Humana’s senior population is that one-third of them have a fall every year. As such, Humana is using advanced analytics to figure out who’s most likely to fall among that senior population, and then enabling them with the right so­lutions to prevent a fall, or making sure that they are in a program in which they have a device that triggers an alert if there’s a fall. “That makes a big difference in their quality of life,” says Gopal. “It increases mobility and confidence, and these are the fundamentals we are tackling, with analytics as the starting point. You need to identify members and communities first, and then put solutions in place.”


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