With 90% of the nation’s annual healthcare expenditures spent on chronic and mental health conditions, there’s an undeniable need for reducing costs while improving outcomes. Population health management (PHM) is an approach that aims to achieve this by prioritizing proactive measures to improve a defined population’s health outcomes.
However, stakeholders need a holistic view of population and patient data to identify trends, risk factors, and gaps in care rather than address health issues on a case-by-case basis.
As Arcadia explains, analytics tools consolidate and organize population data, enabling providers to implement preventive care and early interventions that reduce the need for costly, reactive treatments. Additional tools facilitate wellness delivery to specific populations — for example, platforms that manage employee health and wellness programs enable organizations to provide targeted and proactive care to their employees.
This article discusses the key goals of PHM that providers should strive for as they implement this approach.
1. Enhance preventive care
Healthcare’s primary goal is to improve patients’ well-being, which involves preventing avoidable health issues, addressing conditions early, and effectively managing health over time. A key goal of PHM is to support this preventive care by assessing health risks and mitigating them before they escalate.
Effective preventive care includes:
- Regular screenings: Blood pressure checks, cholesterol tests, cancer screenings, and other routine screenings enable providers to detect risk factors and intervene early. For example, colonoscopy reduces both the incidence and mortality rates of colorectal cancer by nearly 70%.
- Vaccinations: According to the World Health Organization (WHO), immunization prevents 3.5 to 5 million deaths each year. Vaccination programs are an extremely cost-effective way to prevent the spread of infectious diseases, reducing the need to treat people who are already infected.
- Education and counseling: Equipping patients with the guidance needed to make healthy choices empowers them to take control of their health. Many programs that offer counseling on diet, exercise, stress management, and other health tips have been proven to improve outcomes. For example, employees with prediabetes could cut their risk of developing type 2 diabetes by 58% by joining a company-wide, structured lifestyle change program.
With these practices in place, providers not only help patients avoid unnecessary health concerns but also improve overall quality of care. Prioritizing preventive care with PHM ensures that patients receive appropriate and effective treatments.
2. Reduce healthcare costs
As a result of preventing avoidable hospital visits and costly treatments, PHM should also reduce healthcare costs. Its preventive approach reduces costs in three key steps:
- Identifying high-risk individuals: Using PHM analytics, providers identify populations at higher risk for chronic conditions or complications and allocate resources accordingly. For example, providers can determine the risk of expensive treatments for heart attacks or strokes in a population with unmanaged hypertension.
- Implementing targeted interventions: After identifying high-risk populations, providers tailor specific interventions to patients’ needs. In the example above, a provider might promote screenings to encourage patients to manage their high blood pressure before it becomes problematic.
- Streamlining care delivery: PHM software and digital health tools allow providers to manage their data and collaborate with patients on care needs. For example, patients with hypertension can participate in educational programming through wellness technologies offered by their employers or share blood pressure readings with their care team from wearable devices.
When PHM effectively follows these steps, providers reduce the reliance on expensive, reactive treatments to achieve positive patient outcomes.
The hypertension patient, for example, may never experience any symptoms of high blood pressure. Without PHM, this could lead to a heart attack or stroke with no warning, resulting in costly hospital stays, procedures, and rehabilitation. With a PHM approach, the provider identifies the risk, implements a care plan to mitigate it, and helps the patient manage their hypertension over time.
3. Address health disparities
To achieve the best possible outcomes for every patient, providers must consider all the factors that influence a patient’s ability to receive care. Social determinants of health (SDoH) are the non-medical factors that affect a person’s health, such as:
- Income
- Education
- Housing
- Access to healthcare
- Living conditions
These factors pose an especially significant risk to underserved populations, as they can limit access to care resources and, as a result, worsen health outcomes. For example, a diabetic patient with low income and limited access to transportation is unlikely to attend educational programs informing them of necessary changes to their diet and physical activity.
PHM addresses these disparities by offering a comprehensive view of a population's unique needs. Specifically, PHM software gathers SDoH data and compares it to patients' medical information, enabling providers to contextualize patients’ needs and foster inclusion by closing gaps in healthcare access. Using the example above, a provider could direct the patient to telehealth services and virtual education programs.
How do providers know whether they’re aptly promoting health equity? Healthcare dashboards help providers track the success of their PHM efforts by measuring key performance indicators (KPIs) such as population per member per month (PMPM), which measures the monthly cost of providing health services to each member of a population.
4. Boost patient engagement
Effective PHM empowers patients to take an active role in managing their health. Many studies show that self-management positively impacts clinical outcomes, and PHM is the driving force behind it. Providers must equip patients to manage their own conditions by identifying at-risk populations and tailoring interventions.
Successful PHM accounts for the unique characteristics that impact patient engagement. For example, different engagement strategies resonate with different generations, and SDoH factors also play a significant role. In-person educational events won’t reach populations with limited access to transportation, and employer wellness programs won’t benefit the unemployed.
To address these differences, providers’ patient engagement efforts must:
- Rely on comprehensive patient data: Providers need a holistic view of patient data to properly segment their audiences and accurately target communications and interventions. Personalization strengthens provider-patient relationships by fostering trust and individualizing the patient’s care.
- Use AI-driven tools: Automation is no longer the future of patient engagement — it’s the present. AI-driven tools, like predictive analytics, enable providers to send automated messaging tailored to specific audiences. To increase patient engagement, providers must understand the role of predictive analytics in healthcare and leverage this tool to promote preventive care.
- Provide continuous support: PHM enables providers to offer ongoing support by analyzing a population’s long-term needs. Beyond their initial diagnosis, patients may need assistance accessing necessary resources, communications with their provider, reminders for medication and preventive care, and other components of self-management.
When implementing targeted and proactive care across various populations, providers, program directors, and other wellness leaders must evaluate their current PHM strategies to determine whether they truly embrace population health goals.
Assess your tech stack today to identify gaps in your services — providers need robust analytics tools for a holistic view of their community's needs, while wellness program directors need a platform that manages data-driven health initiatives. The right tools and strategies make the difference between delivering care and meeting a population’s health needs
Ready to learn more about wellness technology?
Speak to one of our technology experts today to learn how CoreHealth's platform can help meet your organization's health and well-being goals.
