Many health care organizations – health plans and hospitals alike – continue to debate what it means to provide population health management (PHM). Most have landed on a definition that aligns closely with what PHM means to them, rather than operationalizing an overly broad definition that doesn’t resonate with the populations and communities they serve. This is smart. But what’s missing is the focus on a more important question: What does it mean to create a healthy population?
To begin, it means more than treating members and patients for a specific illness or disease. We must consider all the factors that contribute to health. Caring for the whole person means leveraging prevention by addressing the factors that contribute to illness and disease upfront. By shifting our focus from “sick” care to a true model of “health” care, measuring wellness, social determinants, mental health, engagement, nutrition, spiritual health, etc., we create the foundation of an effective care management program. When we apply this holistic approach to a group of people with similar health needs — a population — we start to create a whole-person care delivery system.
According to John Snow, Inc., a public health research and consulting organization focused on vulnerable populations, the need for whole-person care (WPC) stems from “unmet social, behavioral health, and health needs within vulnerable populations, and from the fragmentation of organization and financing of current health and human services systems.” Health care is moving towards a whole-person care model because it ultimately leads to healthier communities and better population health. It’s time to begin exploring mechanisms for accountability to ensure that we’re delivering whole-person care effectively and broadly.
There are many dimensions to consider when designing a modern PHM program. Some key starting points for creating a whole-person care delivery system to support population health efforts include:
1. Strong and collaborative leadership
Collaborative leadership is essential for developing, adopting, and implementing a whole-person care strategy among community and local stakeholders responsible for serving vulnerable and at-risk populations. This means that aligning wellness, behavioral health, and social service interests while establishing shared goals and accountability is more important now than ever before. Relationships between stakeholders ultimately form the substance of coordination of services, and these relationships take time and energy to foster, especially across the various sectors (i.e., private, health plan, public, provider, etc.). Building social capital throughout the health care ecosystem will be critical to establishing whole-person care business in the future.
2. Targeted populations
A whole-person care framework should include strategies to identify characteristics of, and segment, the target population. Some organizations may decide that addressing an individual’s social determinants of health (SDOH) is their primary strategy for achieving the Triple Aim. For others, the target population for whole-person care might be all low-income populations or individuals who are high health care utilizers. It’s important to take a broader view of whole-person care and expand the target population beyond high utilizers to individuals at high risk and/or emerging risk. In addition, segmenting doesn’t stop at risk evaluation — it should include analysis of the effectiveness of your interventions and care management efforts for the target population. This data allows you to apply resources towards individuals with both the greatest need and readiness to receive services to address those needs.
3. Patient-centric care coordination
Patient-centered care is generally described as providing the “right care, in the right place, at the right time.” In the context of providing whole-person care, this means providing easy access to benefits and community resources as well. This may include activities such as implementing diverse care teams, the use of advanced practice providers, integration of digital technologies, and connecting patients with community-based services. For many organizations, providing the “right care in the right place” means doing so in a primary care or medical home setting that serves as the hub to coordinate whole-person care. For some populations, such as those who are chronically homeless, the most appropriate environment may be in a behavioral health or supportive housing setting with primary care integration. Whatever the delivery method, a patient-centric WPC program makes services available in the environment where the patient is best able to receive them, which can change over time. Patients experience a continuum of health needs, and a single responsible entity and/or a single funding stream should facilitate seamless care delivery across that continuum.
4. Data sharing
Data is the cornerstone for systematically coordinating care across the various sectors and entities. There is great value in sharing data across care settings for the purposes of:
- Identifying common populations
- Coordinating care for those needing services within multiple care delivery systems
- Identifying areas of opportunity for improvement
- Evaluating performance and success
Data infrastructure that allows for clinical, behavioral health, and social services information exchange is an important yet underdeveloped building block of whole-person care. While there can be legal and technical barriers to data sharing, organizations must create effective data interfaces to modernize and increase the speed and efficiency of their care. Using universal consents that support an “opt-out” approach, rather than requiring an “opt-in,” is one strategy for overcoming data-sharing barriers. At a minimum, data sharing can produce a more effective and less redundant care management process. At best, data sharing can transform operations and financial return for the organization while also improving the quality of life for the consumer.
Putting it all together
The above starting points are just that, a place to begin. Your organization will examine and develop many more considerations once your WPC program delivery system is off the ground. For example, a key enabler of a successful WPC program is consumer engagement. The readiness and receptiveness of those targeted to receive care and services are essential to overall program effectiveness. Organizations that understand and develop a formal consumer engagement strategy can better allocate precious resources for maximum impact.
A whole-person care approach is about putting holistic methods into action, using those methods to consider an individual’s life and their vision of self, and providing the resources that person needs to make that vision real. Patient-centric care and whole-person care are one and the same and must be pursued to realize healthier populations. As health care’s key players, we are in this together and can make an impact if the focus, funding, and resources are deployed to the bottom of the health care pyramid where disease prevention, holistic needs, and healthy behaviors are foundational.
Trisha Swift is a health care executive.
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