Role of emerging technologies in achieving population health

• Access for care management teams to LTCF (Long Term Care Facility) EMRs through patient portals or other programs are important for patient management beyond the hospital walls.
  
  
• Remote patient monitoring (RPM) is a new method of management that we are slowly moving into in regards to population health. Thus far, we have found that the additional spending on continuous glucose monitors has been a good investment. The patients enrolled in continuous glucose monitoring (CGM) are being monitored by a care team and are much more compliant because they test their blood sugar, on average, 4x more a day.
  
  
• Texting platforms are extremely important for a successful care management program. Most commercial plans have members that prefer this mode of communication, so a sound texting platform or patient portal with these capabilities is key to finding and engaging patients.
  
  
• A population health program with claims-based data and social determinants of health (SDOH) information is key to identifying patients that are most in need of care management services.
  
  
• A social determinant of health tool to help with closed-loop referrals is a new tool that we recently put in place. This allows us to track our referrals and ensure pts receive services.
  
  
• Health information exchange data that allows care teams to identify patients discharged from external facilities is pivotal in population health.

Most pressing population health challenges and how to resolve them

• Contacting patients can be difficult. Patients often do not answer their phones and do not understand why their healthcare provider is calling them unless they had a recent visit. Therefore, we are in the process of putting a texting platform in place to help with the patient connection.
  
  
• Care managing patients in long-term care has always been difficult. Over the last two years, we partnered with a vendor that provided us with a dashboard into Point Click Care which is the most widely used EMR in Arkansas. Moving into the rest of 2022, we are partnering directly with a local LTCF Clinically Integrated Network to access this information. Our care management team will work alongside their liaisons to better manage our populations.
  
  
• Palliative care has always been a struggle for us, so we created an in-home Palliative care program in 2021. This program allows us to improve the quality of life for these patients, obtain advanced directives for these patients, and help the family better understand the process that their loved one is going through.

Population health strategy

• A well-rounded population health team (RN care managers, Pharmacists, Social Navigators, Pharmacy Techs, Behavioral Health Specialists, Outreach Specialists)
  
  
• A robust analytics tool allows team to identify patients through mechanisms other than just discharge.
  
  
• A population health platform within the EMR integrates with the physicians for seamless care.
  
  
• Physician engagement at all levels. Must have the ability to communicate with the providers regularly and provide them with the support they need to improve their quality of care.

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Population health is a key part of the American Heart Association’s mission of being a relentless force for a world of longer and healthier lives. COVID-19 has accelerated the adoption of technology outside of the healthcare setting not only to reduce exposure to the virus, but also to improve access to care. As a result, health technology has advanced to the level that key biometrics, such as blood pressure, glucose, physical activity, and even heart rhythm, can be captured through wearables and connected devices outside of the healthcare setting and accessed by the care team.

An SMBP platform can bridge between the BP device and the EHR and solve the problem of manual data entry and selective reporting.

An effective population health approach using health technology is one that is high volume, high impact, cost-effective, and promotes health equity. A successful population health/data integration strategy is defined by a positive health metric and an economic value. The strategy must be both scalable and sustainable, so if it does not meet both criteria, it will not be seen as a success. Key elements for successful digital health outcomes include using a trusted source and a scientific approach, connecting to a healthcare delivery system, providing a secure technology and digital solutions platform that allows delivery to very large groups, providing an intuitive, consumer/patient-facing interface, and having the ability to continuously monitor data to evaluate usage and outcomes. In addition, there are numerous gaps throughout the system that make this challenging, including the digital divide, lack of trust and science/validation gaps.

A classic example of population health utilizing a data integration strategy is self-measured blood pressure (SMBP), which is the person taking blood pressure (BP) readings at home, connected to a secure cloud, and integrated into the electronic health record (EHR). Nearly half of the 116 million adults in the US with hypertension do not have their BP under control. Rates of BP control are disproportionately lower among racial, ethnic, and socio-economic groups. High BP is associated with an increased risk of heart disease and stroke and is a vital indicator of overall health. Achievement of BP control is associated with better health outcomes and is cost-effective.

The American Heart Association’s Center for Health Technology and Innovation has been at the forefront of digital solutions for BP control, including community and home-based strategies such as Check.Change.Control and National Hypertension Control Initiative and the Self-Measured Blood Pressure Digital Health Platform Provider Landscape, which provides best practices for BP control, especially in under-resourced communities.

The management of high BP has been based on measurements taken in the healthcare setting. Regular out-of-office BP measurements provide a better picture of the individual’s blood pressure trends and has the added benefit of allowing the patient to be more active participant in their care. An SMBP platform can bridge between the BP device and the EHR and solve the problem of manual data entry and selective reporting. The process begins with the patient being identified for SMBP by a healthcare professional. The patient has access to a secure portal and a validated BP device. The patient takes BP readings at home and returns to the clinic for follow-up. The BP device must be accessible and compatible with the portal. In addition to uploading the data to the EHR, the patient must also be given access to the readings for feedback. The professional must be able to access the readings in a manner that does not break their clinical workflow. The professional must be able to monitor the individual’s progress and evaluate the success of the overall program. To be sustainable, the data must also integrate with the EHR, billing and reporting systems.

The mere existence of home BP monitoring does not lead to blood pressure control. Relaying the readings to a healthcare professional remains a critical step to inform clinical decision-making and action, to diagnose, and optimize pharmacologic and non-pharmacologic treatment plans. Methods of data transfer range from low and non-tech approaches that are paper-based, to intermediate and hybrid approaches of connecting the blood pressure device to an app or cloud-based data portal, to a fully integrated solution from the BP device to the EHR.

The Food and Drug Administration’s approval to market a BP device does not imply that it has been validated to deliver clinically accurate and useful blood pressure readings and the Centers for Medicare and Medicaid require the use of a validated device for reimbursement. The accuracy and utility of SMBP depend on the use of a device that has been validated for accuracy, such as those on the US Blood Pressure Validated Device Listing. Data capture can be from the device, a patient portal, or a mobile application. The data can be shared with the healthcare professional by showing the data during an office visit, via email or external dashboard, or within the EHR. Once the healthcare professional has access, the data must be validated and presented to meet minimum acceptable standards for clinical decisions.

A key challenge is presenting the information to the user in a way that they understand and can use to make good, well-informed decisions, and to the healthcare professionals in a manner, they can trust. For the end-user, this is done by presenting the information in a clear and concise manner with actionable steps. For the healthcare professional, this is done by taking a science and evidence-based approach and providing context. For end-users and health professionals, data security and storage, as well as access and privacy are always important, while interoperability and integration into the EHR is also an important factor. The desired outcome is improved BP control, resulting in improved quality of life for patients and healthcare professionals, and a more accessible, cost-effective, and equitable healthcare system.

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The traditional house call, known by generations of patients and doctors alike, is making a comeback through telemedicine.

With the advent of radio in the early 20th Century, people envisioned how advances in communication and technology could be applied to the practice of medicine. By the 1950s, the term “telemedicine” was referenced in medical literature to describe transmitting radiographic images over the telephone and using two-way television for neurological exams. As America’s space program intensified throughout the 60s and 70s, the need to monitor an astronaut’s vital signs during flight led to satellite-based telemetry systems that further advanced our understanding of tele-, or distant, medicine. While adoption slowed in the 80s and 90s due in part to the high cost of transmission rates, certain programs thrived because of their ability to reach underserved, rural populations. Today it is quickly evolving as a mainstream component of the care continuum.

We now face unprecedented competition in a rapidly changing healthcare marketplace. Telehealth is creating disruptive innovation, compelling healthcare systems to adopt new delivery models to assure long-term sustainability. The shift from fee-for-service toward value-based payment models is increasing the demand for timely access, higher quality care, improved patient satisfaction, and the importance of coordinated and integrated health services across the continuum of care. Digital medicine presents us with the opportunity to serve our patients in the most appropriate setting, which may be their own home. A well-integrated home health strategy supports population health, exploring root causes of poor health, better serving vulnerable populations, and more actively managing chronic conditions. Such programs help to promote quality of life while at the same time lowering the overall cost of care.

Technology that enhances patient engagement is central to developing a robust population health strategy.

Population health initiatives often incorporate a variety of systems, devices, and services that work together to extend patient care in hospitals, specialty clinics, private physician offices, skilled nursing facilities (SNF), home health agencies – and increasingly – directly to our patients. In addition to a generational shift away from traditional care settings, advances in video-enabled mobile technology and smart devices are driving adoption among consumers who want convenience, access, value, and choice. These factors and more are enabling comprehensive care models for chronic disease management that are driving medical devices and remote monitoring into our patients’ everyday lives.

Remote monitoring serves as the cornerstone for many population health programs, and is increasingly prevalent in wearable technologies. Expanding the use of integrated home health devices for chronic disease management not only provides a more insightful view for the care provider but also serves as a potential data mine for population health management and research. It allows for corrective actions in-between regular office visits to assist with managing chronic illnesses such as CHF or diabetes. Likewise, providing patients with virtual access to medical expertise through digital technologies can reduce overcrowded emergency rooms, long wait times, and lapses in care.

Technology that enhances patient engagement is central to developing a robust population health strategy. The explosion of digital health solutions is evidence of the shift in traditional care delivery models toward one that is more consumer-driven and patient-centric. The use of smartphones, wearables, connected monitoring devices, and other readily available technologies expands our outreach to areas that were previously inaccessible to our caregivers. Many of the services that only a few years ago mandated an office visit are now being offered in more accessible and convenient ways through home-based diagnosis and treatment options. There will always be a demand for hospital beds.  But direct-to-consumer models are gaining fast acceptance, particularly among the ever-growing population of “connected” Millennials.

Yet it’s not so much about tech and wires as it is about building relationships between patients and their care providers. While synchronous video has been in use for decades in telemedicine, a new wave of technology has emerged in the form of apps, wearables, and smart home medical devices. Now more than ever, our ability to connect with patients is literally in the palm of our hands. The healthcare industry is flooded with tools and technologies that facilitate ease of access, convenience, choice, and remote monitoring capabilities. Still, technology itself does not constitute a population health strategy.  It is an instrument used to gather data through two-way audio/video conversations, image capture, electronic diagnoses, vital signs, and much more. In order to be effective, that data must become actionable information for the care team because the most relevant information combined with the right action at the right time almost certainly leads to better care.

The goal of coordinated care and population health management is to ensure that patients, particularly the chronically ill, get the right treatment at the right time while avoiding unnecessary duplication of services. In this regard, population health can be very successful in managing so-called “penalty conditions” linked to higher readmission rates. Avoiding readmission penalties is a cost-prevention strategy. As is side-stepping the ED from more proactive care. The value proposition is no longer encounter driven…it is the result of savings across the entire course of treatment. But to do so requires a combination of people, processes and technology to bridge gaps in the continuum of care. That is not accomplished with technology alone. It takes programmatic change and people working with a common purpose. An army of health coaches to improve population health through active and engaged home health monitoring and individualized care management.

For perhaps the first time in modern healthcare, we are witnessing a paradigm shift that will alter the traditional patient-provider relationship forever. Yet, in one sense, it may just be coming full circle…back to the potential of the “radio doctor” as predicted nearly 100 years ago.

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The pandemic has catalyzed the care delivery innovations for the healthcare industry. As many healthcare organizations move towards value-based care, the focus has shifted to patient-centered care. One of the ways we are looking at new ways to provide care is to utilize the virtual platform to provide the proper care at the right time and at the right place. We are increasingly recognizing that the right place can often be the patient’s home, where we can remove barriers such as transportation needs, taking time off from work, caregiver presence, etc. Therefore, virtual care is no longer synonymous with ambulatory settings as it can be in the setting of acute care such as tele- ICU, hospital at home, ED settings as well as e-Consult which is an asynchronous interaction between providers to optimize the care of the patient while avoiding fragmentation of care which means moving away from multiple visits with multiple new providers. Concerns that have surfaced include questions such as whether telehealth can continue to remain an option post-pandemic or that only younger patients in the urban location are the ones who prefer the virtual care option. We will have to continue to observe the trends with time and be flexible to pivot by redefining the scope of virtual care. Our data from west Michigan which includes rural settings currently point to positive patient receptiveness to virtual care. Pre-pandemic, our tertiary care healthcare system based in West Michigan conducted 19,053 virtual yearly visits. We saw an increase during the pandemic with 84,883 virtual yearly visits and these have remained stable. Our data also shows that we impacted 329 more zip codes from 2020 onwards than our pre-pandemic geographical footprint in the virtual care arena.

Value-based care requires primary care redesign to allow patients to get most of their healthcare needs fulfilled by the provider who knows them the best.

Our pre-pandemic top five diagnoses for virtual visits were:

• Acute bronchitis, unspecified (ICD-10-CM: J20.9)
• Acute upper respiratory infection, unspecified (ICD-10-CM: J06.9)
• Acute sinusitis, unspecified (ICD-10-CM: J01.90)
• Rash and other nonspecific skin eruption (ICD-10-CM: R21)
• Cough (ICD-10-CM: R05)

And during the pandemic, the top five diagnoses for seeking virtual care are:

• Anxiety disorder, unspecified (ICD-10-CM: F41.9)
• Major depressive disorder, recurrent, moderate (ICD-10-CM: F33.1)
• Essential (primary) hypertension (ICD-10-CM: I10)
• Major depressive disorder, single episode, unspecified (ICD-10-CM: F32.9)
• Acute upper respiratory infection, unspecified (ICD-10-CM: J06.9)

As noted above, mental health disorders have been an area of focus for us. Based on our data, there has been patient receptiveness to accept the telehealth platform for seeking care for behavioral health needs. The need for easy access to common ailments pre-pandemic points to the need to have various options for patients that can meet their needs to get care quickly.

Value-based care requires primary care redesign to allow patients to get most of their healthcare needs fulfilled by the provider who knows them the best. If we continue to explore new ways to meet patient needs, we can avoid fragmentation of care where patients have to seek care from different providers/specialists for different conditions leading to an increase in the cost of care and poor value for the patients. As we continue to refine our offerings within the virtual care setting, one important new addition worth mentioning is our portable all-in-one medical exam kit that enhances the virtual visit experience. During a virtual visit, the mobile medical exam kit links to a patient’s provider, allowing them to capture high-quality sounds from their heart and lungs and share readings of their heart rate and body temperature or create images and videos that show their inner ears, throat, and skin. Their provider then uses this information to make a diagnosis and offer a treatment plan. It has mostly been utilized by primary care but gaining interest by specialty providers too. With the Mobile Exam Kit, patients can get a diagnosis and treatment for many common conditions, including stomach aches, allergies, sinus pain, bug bites, ear infections, pink eye, fevers, rashes, cold and congestion. This allows primary care to help patients in an acute setting and allows avoidance of unnecessary ED/Urgent care visits. In addition, patients need not have to pay more for a virtual visit when using their Mobile Exam Kit. A single kit can also be used for multiple family members. Our experience has been that patients and providers enjoy the enhanced virtual visit capabilities that the mobile medical kit provides. Patients express their appreciation for being able to see the numerous assessments in real time (such as inside their child’s ear, for example) while completing video visits via the kit. Through traditional virtual visits alone, this type of exam was not possible. Providers now can perform exams that were once only possible in an actual exam room. This simple tool allows us to provide care to the patients at the right time and in their home setting. This decreases the unnecessary demand on ED utilization, allowing costs to remain low for patients from a co-pay perspective. We have completed approximately 2,200 visits thus far, averaging around 350 visits per month. Though the percentage of the mobile medical kit vs. traditional visits is low (approximately 5%), we see it increase a percentage point each month or two with continued awareness campaigns.

Similarly, electronic consultations (eConsults) are asynchronous provider-to-provider consultations (between a primary care provider and specialist) that occur within an EHR. We are utilizing eConsults to take advantage of the expertise of our specialists without increasing the demand for specialty care by increasing the referral rate, which leads to long wait times for patients. eConsults provide another ramp onto the telehealth superhighway, to enable specialty practices to explore novel ways of coping with the national shortage of specialists coupled with increased demand for access.

The above have been some ways that have allowed us to leverage virtual health platforms to provide care differently. The virtual health space will continue to grow as we think of new ways to provide care to our patients focused on their convenience while maintaining quality. Outside of acute and chronic disease management, virtual care can be an essential pillar for setting up preventative care models as the healthcare system continues to expand in the population health space.

Acknowledgment (non-author contributors at Spectrum Health): Jared Cowan (Operations Director, Virtual Health), Alexia Eaton (Database specialist, Virtual Health), Michelle Rizor (Principal Strategic Partners, Virtual Health), Dr. Rima Shah (Chief of Primary Health).

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The post-acute sector, specifically in the skilled nursing arena, continues to quickly evolve and change, as the landscape of payment shifts from a fee-for-service model to that of a value incentivized model, becoming prominent across all care settings. Population health, historically seen in the acute care and managed care industries, is now making an appearance in the skilled nursing facility (SNF) industry setting to strategically balance stakeholder needs, prioritize the emphasis on positive outcomes and right-size care.

Population health began as a concept in the early 2000s and since then, has become a specialized division of health care that focuses on the Triple Aim approach to healthcare delivery. Triple Aim refers to an approach developed by the Institute for Healthcare Improvement that focuses on enhancing the patient experience, improving the health of populations and reducing healthcare costs.

Moving forward with this approach in the SNF sector is even more essential as they face substantial decreases in medicare payments. This strategic shift, however, does not happen overnight and takes the expertise of guided coaching by outstanding execution-driven population health experts, with a long history of performance success with processes and outcomes. The adoption of population health in the SNF care world requires integration of technologically advanced data management software that compiles outcome reports which inform the strategic interventions to be applied to the population in question. One such progressive system, providing the most current data analytical systems is CORE Analytics developed by Zimmet Healthcare Services Group, LLC. CORE Analytics is a claims-based software application that leverages current claims for post-acute care performance measurement. Population health provides a proactive, comprehensive approach to patient care; and interpretation of outcomes, disease state and social determinants of health (SDOH) data. Investing in software programs, such as CORE Analytics, enables real-time outcome reporting and ease of trending multiple data points that will increase the ability to effectively mobilize population health. However, outcome reporting and advanced software applications are only one part of the equation. To fully capitalize on what population health principles provide to an SNF organization, the utilization of software programs exclusively is not enough. Therefore, it is paramount that population health specialists interpret and translate data to our upstream and downstream partners to develop clinical programming with a solid information technology team, who have a strong commitment to population health priorities. These strategic interventions focus on programming within a subset of patients that are supported by evidence-based care protocols. Clinical programming that aligns with the specific needs of the unique population is an important part of the model.

With the industry emerging from the pandemic where it faced unrelentless scrutiny, and in the midst of funding and reimbursement cutbacks, implementing population health principles can provide the platform to shift the public narrative and strengthen fiscal performance.

In addition to robust data analytic software, a complete transition to an electronic health record (EHR) platform and health information exchange (HIE) will provide the transparency needed. Integration of clinical decision support (CDS) systems and software will also help decrease overall healthcare costs and improve quality. These tools should be enhanced from what already exists in the facility. Organizations should look to health information technology and nursing informatics experts to guide the curation of new support tools as well as the enhancement of tools already in place. Enhancing the ability of the clinician to make sound decisions supported by evidence and protocols will help achieve overall success for the organization, facility, patient and health care team members.

With the industry emerging from the pandemic where it faced unrelentless scrutiny, and in the midst of funding and reimbursement cutbacks, implementing population health principles can provide the platform to shift the public narrative and strengthen fiscal performance. 

Population health in skilled nursing will facilitate producing a valuable product where patients come first. Through this delivery of high-quality, low-cost care, the SNF industry can begin to re-establish itself in a new light. In doing so, this can ultimately attract more career interest and workers to the field and help alleviate the unprecedented staffing shortages that are being experienced related to the SARS COV-2 pandemic.

The analytical, strategic approach to population health management by leaders in post-acute care, help clinicians close gaps in care, uncover opportunities around financial vulnerabilities, align with stakeholders and above all, increase the quality of care provided to the patients. 

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It is predicted that 40% of the fortune 500 companies will no longer exist in 10 years. The average lifespan of a company listed in the S&P 500 has decreased from 67 years in the 1920s to 15 years today. Companies that do not embrace the market transitions quickly, and adapt to the changes in the market, can become irrelevant very quickly. 

The Healthcare Paradigm

The healthcare industry faces significant challenges to remain competitive in the marketplace. We have the task of delivering high-quality healthcare, under an incredible number of financial constraints and stringent government regulations. For example, in the United States, healthcare is close to 20% of the total Gross Domestic Product (GDP); however, it operates under small profit margins at less than 2%. This healthcare paradigm forces growing healthcare systems to be highly innovative and utilize an agile mindset, to keep up with the ever-changing market. With a large percentage of the US population currently depending on Medicaid and Medicare programs, healthcare systems must regularly seek out and provide unique services to meet each patient’s needs. This involves a different approach which involves working in collaboration with local “competition” to develop and implement proactive programs in the community, to improve the healthcare outcome of its population. Naturally, the highest utilizers of health care resources become the central focus of population health management. 

Consumer-centric perspective

Population health management goals drive the need of innovating for high-quality, patient-centric care, and a reduction overall healthcare costs, especially for our highest utilizers. This creates new challenges as well as opportunities for providers, especially Northwell Health, which has a service area covering over 20 million patients throughout the NY metro region.

Patient-centric care requires a high degree of coordination internally across our organization, with a high level of trust and collaboration across clinical, operations and technology staff.   Externally, it requires us to develop robust relationships and partnerships with many community entities that support and build our communities, including community-based groups, community and faith leaders, Department of Health, vendors etc. Recent partnerships undertaken by Northwell Health include external organizations such as Community Based Organizations, Care Management Agencies, Independent Physician Associations, Skilled Nursing Facilities (SNF), and yes even “competing” healthcare systems!

Emerging Healthcare Technologies

To achieve operational excellence, we had to reimagine the things we do, and ask ourselves how could it be done better? Everything we do, should ultimately add value for the patient, the improvement of care, and overall health. At the end of the day, our goal is for our communities to be well educated about health care and their healthcare options to ultimately remain healthy!

Our technology transformation journey is fueled by our growth mindset, which has contributed our agility as a large health system, to quickly adapt new and innovative solutions in the marketplace. To achieve our transformation goals, we are regularly on the lookout for emerging technologies that serve the healthcare industry and help us address the healthcare paradigm. Digital population health initiatives, brings transformative technology to our health system. Some examples are telehealth, robotic process innovations, direct messaging, chatbots, artificial intelligence (AI), machine learning (ML), analytic tools, etc help us identify high utilizer patients, outreach them and keep them out of the hospital. 

Population health projects by nature, have inevitably needed Northwell Health teams to transcend beyond our traditional approach to projects, which was once focused on enterprise system-only initiatives. Instead, we function as part of an eco-system relying on each other for information, strategies, research, collaboration, implementation, and lessons learned. We have an extensive evaluation program producing evidence-based research using clinical, claims, and other quality indicators. In addition, we have spearheaded collaborative partnerships with the New York State Department of Health (NYSDOH), through the Delivery System Reform Incentive Payment (DSRIP) Program, on Health Information Technology improvement programs. We collaborate with other health systems by sharing information which helps us to meet our collective end goals in population health. Our common goal of coordinated patient care and high-quality care delivery connects us all.

It is truly an art and science to work in a digital world, balancing just the right amount of technology interference, with compassionate human interactions. An organization’s ability to learn, translate that learning into action rapidly, is the ultimate competitive advantage. Our new technology initiatives are tested using a pilot approach with 1 or a few small groups. For example, 3-6 months post-implementation, we collect analytics and perform a detailed evaluation. This informs us and helps our leadership make decisions around the expansion or cancellation of an initiative. If it makes sense to continue, we expand the initiative with multiple use-cases, or might even move towards an enterprise-wide implementation. To implement large-scale integrated delivery system reform initiatives, we adapt and build flexibility into our project management methodology and processes. These tools allow project teams to plan, estimate and assign resources, and accurately track work performance data, including value and ROI.  

Digital disruption or transformation is much needed to deliver high-value collaborative patient-centric care which transcends the boundaries of the hospital.

Technology Transformation journey

Healthcare systems must realize that technology-driven change is quintessential to thrive, or even survive in the current marketplace.Digital disruption or transformation is much needed to deliver high-value collaborative patient-centric care which transcends the boundaries of the hospital.    

At Northwell Health, our population health team focuses on consumer-centric healthcare.We regularly participate in nationwide industry technology groups and healthcare forums, which feed collaborations and help us make informed decisions regarding the next new and innovative solutions in healthcare. Automating, and scaling emerging technology solutions has allowed us to develop a path and thrust forward with our own technology transformation in the healthcare journey

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The recent pandemic years have changed many aspects of healthcare, from how it is delivered to how it is paid for and subsidized. With limitations on in-person interaction and extreme staffing shortages, many aspects of the provision of care that were previously deemed secondary or had only limited use-cases, have now entered the mainstream. Chief among these is Telehealth which has finally become a more convenient option for care provision, instead of being regarded as unique or pioneering. Similarly, Remote Patient Monitoring (RPM) is seeing expanded use beyond specialized areas of hospitals, as the technical ability to remotely ingest device readings into the patient’s record over the web has matured. RPM has especially found import in long-term care where ongoing treatment plans are based on readings provided by devices such as blood pressure cuffs, glucometers, pulse oximeters, and others.

Many envision a not-so-distant future where healthcare delivery lives, for the most part, beyond the hospital walls. And it is this future-state of a distributed model of care that will have a profound effect on population health.

By 2030, 20% of the U.S. population will be over retirement age. This means that in about seven years’ time, there will be a tsunami of demand for geriatric care, one that would easily overwhelm our population health initiatives and resources, if it were to happen today. It seems prudent, then, to build for this future today.

Some provider organizations are seeing the writing on the wall and are beginning to invest in at-home hospital programs to prepare. The idea here is to be able to provide services, whether urgent care, skilled nursing, infusion, or even hospital-level acute care, right in a patient’s home. While this approach is not new, many facets of our recent societal and digital evolution have made the environment even more fertile for it today. For example, the success of an at-home program depends heavily on the social determinants of health (SDOH) for a given population, which includes whether the recipient of care lives alone or has a support system around them each day. With remote work now a reality, this has shifted that variable drastically – it is more common now for multiple generations to be together at home, while maintaining full-time remote jobs, and supporting each other’s daily needs, from child care to meal preparation. It is, therefore, not inconceivable to imagine that in 2030, more of the older population would have full-time family support at home, while their designated care providers would come to them, to check-in periodically with supplies, meds, clinical consultations, and education. This would have positive downstream effects on healthcare providers as well, with an easing of pressure on their emergency departments and in-patient units – areas that had previously been stretched to a breaking point at most hospitals at the onset of the Covid-19 pandemic.

With telehealth now mainstream, in combination with RPM, we are seeing meaningful strides towards large-scale care management, especially when there is an established relationship and the patients are enrolled in programs with their providers.

The distributed nature of population health has long been a challenge as well; when gauging the success of a population health program, a key factor is the care-provision sites’ ability, whether they are hospitals or clinics, to provide services in a dependable manner to the communities in their immediate vicinity. With telehealth now mainstream, in combination with RPM, we are seeing meaningful strides towards large-scale care management, especially when there is an established relationship and the patients are enrolled in programs with their providers. Unfortunately, there are still many scenarios that illustrate gaps in our care models – for example, if you require urgent in-person care, do not have access to an appropriate treatment site, or if you lack an ongoing provider relationship, it is likely that your only options are to either not seek care, complicating things further, or to opt for emergency care instead. It is scenarios like this that continue to pose challenges to a comprehensive population health approach. There is a budding solution in this arena, however. One that requires many pieces of infrastructure that we now already have today, thanks largely to the transformation spurred on by the pandemic – on-demand at-home urgent care through both, in-person (also known as “mobile”) and telehealth visits.

Again, while the idea of on-demand mobile urgent care is not new, it has not yet had its time in the limelight. There do exist some firms that provide such services as an out-of-pocket expense in very limited geographies. However, most, if not all, such programs are small mobile-nursing-based companies with limited offerings and minimal diagnostic capabilities. And much like how shifts in reimbursement during the pandemic allowed Telehealth to go mainstream, to allow the disparate pieces to fall into place for this, there would need to be a focus on it by both provider and payer organizations. The “mobile” aspect of such care offers an obstacle, since it requires purpose-fitted transportation, loaded with appropriate supplies through an established supply-chain, manned by care teams that deliver on-demand location-based care, akin to rideshare platforms with delivery services.

Historically, creating an entirely new program, especially one that radically changes the mode of delivery, has been a hard thing for providers to achieve quickly at scale. Fully-integrated provider organizations with their own insurance plans and ambulatory networks do have an edge; they are able to see benefits in their communities even today, when offering at-home and/or on-demand care, even when the policy aspect and outside reimbursement have not quite caught up. This leads one to infer that it will likely be these very same organizations – which choose to invest in this realm of care provision, using the latest in digital health to extend their clinical resources – that will likely find themselves being approached by other keen health systems looking for a population health partner in the near future.

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Colossal data volume is one of the salient aspects of population management. If unlocked, healthcare and public sector organizations can benefit a great deal from the insights and build useful solutions across the healthcare value chain. Buxton, a consumer intelligence company, SaaS developer, analytics partner, and trusted advisor to many organizations, has a compelling record of serving over 300 active clients, including health systems, specialty health and retail health. By helping clients connect the dots starting from identifying and categorizing patients geographically, demographically, and psychographically, Buxton helps them reach new potential. They start with building site selection solutions to operate in the most conducive ambulatory locations, enabling convenience and accessibility to patients and consumers. “To do this, we combine our client’s data with hundreds of our unique datasets to identify the patterns or combinations of data that can predict performance, by service line or business requirement. We create actionable insights that support real estate, operations, and marketing needs,” says Bill Stinneford, SVP, Buxton.

Leveraging Over 600 Unique Datasets!

The firm has over 600 unique datasets ranging from household-level data to payor mix data to mobile data that are used to create solutions for clients. Their datasets include demographic information for over 128M households in the U.S., up to 8 individuals within the household, psychographic/behavioral segmentation data, outpatient demand by service line and inpatient demand by MDC and DRG. Lastly, their data spans  covered lives by payor type at the patient zip code level, healthcare points of interest across the U.S. and mobile datasets that adhere to user security and privacy best practices. Using demand, supply, psychographics, demographics, and other data, Buxton helps identify the best, most convenient  locations to serve a group of patients. For example, Cooper University Health Care used Buxton’s analytics to optimize outpatient location growth and expand its ambulatory network beyond Camden, NJ.

During the pandemic, many clients became even more intentional regarding payor mix for their deployment of limited capital, providers, and marketing resources. Buxton helped private equity-backed specialty health clients who were looking for locations with the highest commercially insured population. They were also able to cater to pediatric dental clients looking to locate in underserved, high Medicaid trade areas based on the good reimbursement rates for pediatric dental services. “The pandemic forced Buxton’s clients to become laser-focused on the efficient delivery of services while accounting for constrained resources and tight timelines. In turn, we developed solutions to accommodate a wider array of business questions with minimal to zero development time required,” Stinneford continues. “We supported the placement of pop-up COVID testing sites and  back-to-school testing for major universities. Buxton has the experience, data, and solutions to support billion-dollar decisions all the way down to a simple question from the same environment.”

RWJ Barnabas Health has also used Buxton to develop access strategies via brick-and-mortar or digital to resonate with consumers’ changing needs and preferences. Additionally, other clients have leveraged Buxton for data and analytics to understand the  potential of an existing healthcare facility, improve the performance accordingly, and add appropriate service lines to facilities that do not already offer them. “This way, clients can maximize their limited capital and staffing resources at facilities with the highest opportunity for success,” adds Stinneford.

Buxton also helps clients go beyond demographics to understand patient lifestyles, communication preferences, and likely healthcare needs to support patient acquisition efforts. Buxton’s patient acquisition and retention solutions help them know who their patients are for each service line so they can utilize those insights to market to the most valuable potential patients with the right message and right marketing vehicle. “That way, our clients can stop marketing to thousands of consumers who are not good prospects simply to reach the ones who are. Reduce waste by using a targeted approach and channel the savings into other marketing initiatives that allow them to grow their active patient base efficiently and effectively,” elaborates Stinneford.

We often refer to our clients as being some of our best developers, as they help us think about new and unique solutions using our data and tools,” explains Stinneford.

Meeting Clients Where They Are

Buxton meets their clients where they are, based on their specific needs. “We offer both custom solutions and platform-only solutions. We surround each client with a client management team that facilitates every step of the process from onboarding, development/implementation, training, and ad hoc analytics support. Our client management team acts as a confidential and objective extension of the client’s actual team,” Stinneford says.

SCOUT, Buxton’s flagship platform that offers consumer analytics and mapping capabilities is built on a Google Maps architecture, which makes it easy for clients to visualize and report on a variety of insights that support their business needs. Clients using the SCOUT are able to envision existing facilities, including patient households, average drive times, outpatient demand, providers and locations, payor mix, consumer, market and demographic data as well as general points of interest, including businesses, educational institutions, retail centers, and more. “We often refer to our clients as being some of our best developers, as they help us think about new and unique solutions using our data and tools,” explains Stinneford. For instance, the company is in the process of rolling out a new SaaS application called “IQ” that clients suggested; the new app allows users to answer macro-level questions with intelligent data queries at scale. Clients will be able to query a combination of their own data and Buxton’s data to answer questions in five broad categories related to: client locations, public places (not owned/operated by the client), consumers, standard geographies (markets, zip codes, etc.) and specific brands. Also, Buxton is beginning  development of a Social Determinants of Health (SDOH) solution that will enable their clients to analyze the key areas that impact health outcomes, including economic stability, neighborhood and physical environment, education, food, community, and health care system.

To continue contributing to the healthcare industry, particularly population care, Buxton draws its learnings from the other verticals they serve, including retail, restaurant, public sector, and private equity. Buxton’s wide variety of clients requires that they maintain datasets to support each of their industries. As such, clients in unrelated industries benefit from the access to this data as innovation in care delivery models accelerates as the lines between healthcare and convenience-based industries continue to blur.

“A better understanding of lifestyles, coupled with the data we collect, enables healthcare organizations to know where to direct specific resources,” Stinneford concludes. “This level of insight gives organizations information they need to do their part in improving population health.”

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The mission of the Northwell Population Health Informatics team is to improve population health and community outcomes through informatics and underlying technology. The COVID-19 pandemic expedited the need for some of this technology such as digital remote care and drew more focus to population health initiatives. While it shouldn’t take a pandemic to raise the importance of population health in the minds of the general public, that is exactly what happened in these last two years. The pandemic has allowed this focus on population health to be consistent for a significant amount of time, widening a pathway for us to learn through numerous areas of concentration Including the increase in utilization of video-based technology, the CMS Hospital at Home waiver, and Remote Therapeutic Monitoring.

One such area of focus for us was the rapid expansion of telehealth services at Northwell. While telehealth became a commodity during the COVID-19 Public Health Emergency, we have been looking into it for many years. Northwell went from having 200 clinicians on its telehealth platform prior to the outbreak, to more than 8,000 clinicians, nurses, and office managers in 2020. From April 1, 2020 to April 1, 2021, the health system performed nearly 500,000 telehealth visits. With this expansion of telehealth services, we are now looking to grow video-based telehealth into remote monitoring-based telehealth. There is no doubt the pandemic assisted in speeding up this process.

The COVID-19 pandemic expedited the planning, implementation, and adoption of numerous digital initiatives including the expansion of video-based telehealth, the proliferation of the Hospital at Home program, and the establishment of remote therapeutic monitoring.

This brings us to another area of focus:  remote care. Our areas of study around remote care include the preferences of our patients, consumer reasons for certain visits, and the needs of specific populations. One example of these needs would be the social issues impacting the use of remote care and how remote care may potentially assist vulnerable populations who cannot afford to travel to seek the healthcare they need. Prior to the pandemic, remote care was sparsely used. Some populations preferred remote care, and some required it due to barriers to mobility. However, most patients would by default go in for an in-person visit. With COVID-19, this idea was flipped on its head. Now, if it is an emergency, then you can come into the office. Otherwise, to avoid contact during the pandemic, remote care would be the default option for all. We expect patients to be driven by individual preferences regarding the type of visits they wish to have moving forward.

The pandemic also helped raise the need for more comprehensive remote care options for non-COVID related ailments. At the height of the COVID-19 Public Health Emergency in 2020, patients had to be turned away from hospitals due to a lack of available beds. Some normally hospitalized cases couldn’t even make it through the hospital door. At the same time, other patients who sought care were too afraid to even set foot outside their homes. We needed to break the walls of these inpatient facilities and figure out a way to expand access to high-quality inpatient care out to the community. CMS first provided the opportunity by establishing the Hospitals Without Walls program in March 2020, and then the Acute Hospital Care at Home program in November 2020.These changes coupled with the success of hospital at home initiatives at other large health systems gave us an opportunity to align a population health benefit to the financial incentives in current inpatient contracts. Now, we have the opportunity to provide the same level of care and receive the same level of reimbursement. At the same time, eligible patients normally admitted into an inpatient ward could be treated in a remote hospital unit in the comfort of their own homes.

Another area of focus for us related to remote care that was elevated by the pandemic would be the expansion and availability of remote therapeutic monitoring. While CMS had previously established reimbursement rules for remote patient monitoring (RPM), it has now introduced reimbursement rules for 2022 related to remote therapeutic monitoring. Where RPM allowed reimbursement for the monitoring of physiologic data only, remote therapeutic monitoring allows for the use of medical devices that collect non-physiologic data such as medication adherence and pain level. In addition, where RPM has a limited subset of clinicians that can bill for the service, the intention of remote therapeutic monitoring is to expand this service to a larger swath of clinicians such as nurse practitioners and physical therapists. Finally, where RPM requires the medical device to automatically record and upload patient physiologic data, remote therapeutic monitoring allows for self-reported data to be part of the non-physiologic data collected.

One final area of focus for our team that was spotlighted by the pandemic has been social determinants of health. While a person’s environment has always affected their health outcomes and risks, it was the pandemic that showed how truly urgent a priority it is to incorporate social data with clinical data to support care decisions and address social justice. During the pandemic, Northwell won a Phase 1 award in the Administration for Community Living’s Social Care Referrals Challenge competition by working with CBOs to aggregate referral data from multiple care settings and eliminate duplicative workflows by streamlining the referral process for Northwell Health’s care teams to create referrals, CBOs to receive the referrals, and for the referral results to be shared back with Northwell Health.

The COVID-19 pandemic expedited the planning, implementation, and adoption of numerous digital initiatives including the expansion of video-based telehealth, the proliferation of the Hospital at Home program, and the establishment of remote therapeutic monitoring. We are looking forward to learning how these technologies and others move the needle with respect to improving population health outcomes and reporting on a successful digital transformation. We also look forward to creating blueprints for scalability and sustainability of these initiatives and understanding the opportunities for improvements to move the needle even faster with a higher value for our populations in the future.

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Essentia Health’s Population Health Strategy begins with our Mission of “We are called to make a Health Difference in People’s Lives”.

This lays the groundwork for advancing three fundamental pillars in population health:  risk-based payer contracting, expanding innovative chronic care models and screening for social needs and social determinants of health (SDOH) for all patients, whether in our clinics or our communities.    

Essentia Health has been on a journey for several years to move from a payment system that rewards us based on the volume of services provided to one based on the value of those services. Essentia holds thirteen Total Cost of Care payer agreements totaling 190,000 at-risk lives in Medicare, Medicaid, and Commercial populations. Approximately 42% of our Fee-For-Service revenue flows through these agreements. Negotiating value-based, risk contracts is a key driver to our success as an ACO and Integrated Health System.

Essentia is improving the quality of care, lowering the costs of care, and engaging our patients with their care while extending our work in our communities.

Our Five-Year Population Health strategy calls for growth in ACO lives with annual improvements and reductions in bending the costs of care across all populations.

Our Approach

A critical success factor in improving the health of our patients is to identify those patients who need care the most. This is done by integrating claims data from the payers with EPIC’s EMR. This approach allows us to risk-stratify the populations and focus on high-needs patients, rising-risk patients and patients who need basic wellness and prevention care (e.g., annual visits), or preventive care measures such as health screenings and flu shots. In addition, any care provided by Essentia is captured nightly to inform outreach through our care coordination platform, Healthy Planet.

Our work focuses on collaborating and connecting with the clinical practice. In fact, we view ourselves as an extension of the clinical practice. Care coordinators develop care plans and coordinate transitions of care with physicians, hospitals, skilled nursing facilities, specialty providers, ambulatory centers, and community resources. We use standard workflow to evaluate patient risk and connect the evidence-based protocols to better outcomes.

Prior to COVID, we offered limited retail e-Visits and Remote patient monitoring (RPM) only to high acuity Chronic Heart Failure patients. When the Pandemic hit, we fast-tracked the adoption of digital technology. With the technology platform in place (built), we were able to move quickly to direct-to-consumer services that kept our patients safely in their homes. Today our direct-to-consumer (DTC) digital programing includes on-demand Video Visits, retail e-Visits, RPM, and our CMS Hospital at Home Waiver program.

This model of care is generating higher patient satisfaction scores, showing we are truly improving the patients’ experience. Recently, we expanded RPM to chronic conditions such include as cirrhosis, diabetes, oncology, and heart failure. 

Value-based Results   

Overall, Essentia is improving the quality of care, lowering the costs of care, and engaging our patients with their care while extending our work in our communities.

In 2020, we reduced total costs of care by 3.50% after accounting for trend. Our successes came from understanding the unique opportunities in each population and using data and technology to improve the care model. With well over 650,000 telehealth visits since the pandemic and by expanding RPM program, conservatively speaking, our work generated savings of approximately $2.5M across Medicare, Medicaid, and Commercial populations.

Another measure of engagement is tracking the utilization of patients using MyChart. Today, 86% of all ACO patients are actively using myChart for prescription refills, lab results, scheduling appointments, reference guides, advance care planning and messaging to the provider.

Community Health  

We recognize the importance of working collaboratively with community partners. We engage with community members, organizations, and local public health to problem-solve solutions in areas identified through the Community Health Needs Assessment (CHNA). Community Health Workers and Community Relations compliments this work as well as the work of operations and other areas of our organization, by developing deepened connections with key stakeholders and ensuring we’re responsive and accountable to uplift our communities.

Our community-giving strategies are moving from annual plans to longer-term impact on the Social Determinants and are focused on the health and vitality of our neighborhoods through housing, child-care, and mental health training, etc. Shorter-term efforts focus on food banks, farmers’ markets, and transportation. Our community investments are designed to improve health, lessen inequities, improve access to health care, and strengthen the fabric of our communities. Our approach is centrally supported and locally delivered. 

Impacting SDOH

While working with a patient to address an immediate social need can be impactful for that individual, addressing the complexity of SDOH one patient at a time is unlike to make the lasting, systemic change needed for making substantial improvements in the root causes of health disparities. In addition to the direct service provided for patients through this program, Essentia Health is also collecting valuable data that can support system change at the community level.

By working across multiple levels of impact (individual, organizational, community), Essentia Health is analyzing the broader context around poverty and inequity in the community. The focus is on identifying root causes, resource gaps, improving communication, and coordination among services/resource providers. 

Technology innovation was identified as a necessary strategy to improve performance, particularly for unmet social needs. To generate a baseline of needed information, a social needs questionnaire in MyChart (patient EHR portal) was developed and automatically assigned to all patients prior to their visit. It is also included in the rooming process for patients who are not active on MyChart. The questionnaire has been sent with 1 million encounters and completed 420,330 times (46% response rate).To meet patients’ social needs identified through this screening, we employ community health workers to connect with patients and recently launched a web-based tool which supports patient referrals to community social service agencies.

In Summary

It is through the support of leadership, our innovative risk-based relationships with payers, digitally expanding chronic care models and integrating the social needs of our patients into their clinical care plans has allowed us to take a more compressive and holistically view of improving the health of our patients and communities which we are privileged to serve.

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