Population Health in Action
Population Health means people first. It also means translating financial risks into real solutions where teams understand utilization patterns, workflow, and quality of care. The ability to dive into data, retrieve the essential information, and then effectively communicate it for better collaboration and systems changes matters.
The real usefulness of population health lies in imagination and innovation focused on elevating responsiveness through technology, person-centered collaborations, and the right prompts to behavioral change. Network management and optimization, transitional care management, waste management, and lowering high-risk utilization begins with an application of advanced analytics to large datasets routinely locked in disparate legacy systems or incongruent architectures.
Many healthcare systems are overwhelmed, stymied, and stagnated by too much data presented in complicated and dissimilar ways. Consequently, reducing readmissions and unnecessary Emergency Department visits and improving health outcomes, specifically for patients who have chronic conditions, becomes increasingly difficult. Undisciplined and unfocused population health strategies leave teams unable to take advantage of proven treatments, clinical techniques, technology, and skilled staffing models to realize success in value-based models.
Predicting patterns and understanding behavior is vital for improving efficacy in care coordination and getting individuals and communities to be more involved in positively changing health outcomes. Advancements in technology and analytics have helped boost capacity in purposefully organizing interventions and disseminating information across sectors—and directly to consumers and communities.
Today, we are working on several innovative initiatives bringing population health into the forefront with action. In two major cities, we are examining significant associations between salt, fat, and sugar levels in school lunch menus, food insecurity, and the impact on child behavior and school performance. Food insecurity, along with childhood asthma, oral health, and a few other key health status indicators in children, are strong predictors of school absences, gaps in child learning, classroom disruptions, and teacher dissatisfaction. The long-term costs to municipalities correlated with more deficient diets in schools are consequential and directly linked with criminal justice, public safety, unemployment, and safety net healthcare costs. Shifting a few pennies forward towards better food quality, nutrition, and access will both save a lot more dollars later and improve the overall quality of life for several communities.
We are working with faith-based organizations to examine ways in which they can collaborate with managed care plans and providers to strengthen care coordination efforts in their communities. Many faith-based organizations have available physical space, transportation, and knowledgeable parishioners capable of serving as on the ground teams for health plans and providers. Churches, recreation centers, and congregations with national networks often serve as central hubs for meetings, food distribution, health education classes, and preventive health screenings. Faith-based organizations are learning to build frameworks enabling them to collaborate with providers, patients, community employers, social service organizations, payers, public health agencies, home care, and even labs. Most are using this knowledge to improve grant writing to foundations and proposals to local government for added resources and funding to support their work. Several have begun to negotiate with managed care plans establishing contractual agreements as vendors and qualified service providers.
We are instrumental in helping schools, faith-based organizations, federally qualified health centers, hospitals, and other community-based stakeholders understand and better use data. Our work advances the best intelligence of historical demographic and public health data sources, claims data, pattern recognition, logistic costs, and behavioral studies. Actionable population health brings solutions to the considerable challenges in building data aggregators that are flexible enough to support diverse applications, file formats, and standards across the population health ecosystem. We’re delivering predictive analytics, data integration, and spatial analysis and mapping through customizable mobile visualization.
Data must tell a story about the health of the population, and that story must connect substantively and definitively.
We’re building interventions to test outcomes where providers, insurers, and consumers connect with directional push notifications, minimal text messages, and meaningful alerts. The future of chronic care management and community-based interventions requires on-demand capacity, precision preventive models, straightforward communication, and useful visual cues. Dynamic partnerships between health plans, providers, and community stakeholders foster accountability and real value. Using data to build core competencies and coordination teaches groups how to work together to improve environmental and population outcomes.
Meaningful. Forward. Momentum.
Public Health Values | Purposeful Analytics | Pharmaceuticals | Complementary and Alternative Medicine | Person-Level Measures | Social Determinants | Global Reach