Population health, defined by Kindig and Stoddart as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group,” is a crucial strategy. At its core, it focuses on delivering the right type of care to specific patient groups, ultimately leading to improved patient outcomes and lower costs.
"Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. This includes health outcomes, patterns of health determinants, and policies and interventions that link these two." – Kindig and Stoddart
The idea, while not new, has been solidified into a framework by the Institute for Healthcare Improvement (IHI) known as the Triple Aim population health initiative. In this framework, there are three main areas of improvement tied to optimizing performance of healthcare systems:
- Patient care experience
- Population health
- Per capita healthcare cost
As healthcare organizations transition from volume- to value-based care, these goals will play an even more important part in ensuring the success of that change for both providers and patients.
A 3-Step Approach to Improving Population Health in the Telehealth Age
While many healthcare organizations have already put plans in motion for their population health program, there is an integral component that could help with reaching the ideal state faster: telehealth and remote patient monitoring (RPM) solutions. Here, we’ll break down a three-step approach to population health using telehealth and RPM that will help to improve patient outcomes, optimize utilization, and lower costs.
Step 1: Understand the population
Begin with a population segmentation analysis to understand how you can prioritize your patient groups based on factors like age, disease, demography, and risk. Several factors could be considered simultaneously when segmenting populations, but typically each category is tied to a risk level.
Once the risk stratification is established, you can identify the appropriate level of care and assign a strategy for each strata. With the right action at each stage, healthcare providers can help patients better manage their overall health and prevent costly readmissions.
Step 2: Identify risk factors
The next step is to identify the population segment’s risk factors as these are responsible for common chronic diseases and how they progress. Risk factors broadly fall into non-modifiable and modifiable categories. For healthcare providers, monitoring the modifiable and intermediate risk categories forms the basis of an integrated approach to improving population health.
This is made easy with remote patient monitoring. Patients enrolled in a telehealth program receive a communication device paired with Bluetooth peripherals that track their health data in real time, like oxygen saturation, blood pressure, glucose levels, temperature, and cardiovascular function. When these vitals reach sub-optimal levels, clinicians can quickly respond and educate patients on next steps to keep their health in check.
Step 3: Improve patient outcomes
The shift from volume- to value-based care means there is greater emphasis on patient outcomes. The change will continually evolve as new technologies and challenges emerge, but healthcare providers could benefit from mapping out the current and ideal state of their processes to stay on track.
- Communication around hand-offs
- Status quo: The American Academy of Family Physicians (AAFP) highlighted serious gaps in patient understanding during the discharge process. Information retention is poor, with patients forgetting up to 80% of discharge and care instructions after their visits.
- Ideal state with telehealth: Teach-back quizzes help assess and ensure how well patients understand post-discharge instructions and their care plan instructions. Patients can review their scores and take quizzes repeatedly until they fully understand their condition.
- Post-discharge follow-ups
- Status quo: Nurses perform a post-discharge follow-up phone call to check on the patient’s health status, medication adherence, appointment status, and any issues that may arise. Documentation is largely manual and patient care is dependent upon the patient’s honest responses.
- Ideal state with telehealth: Before the scheduled follow-up call, the nurse can check the platform for the patient’s most recent vitals, biometrics, and medical adherence, as well as clinical documentation from the last visit. During the call, the nurse can then focus on reviewing the patient’s care plan and asking pointed questions based on the health data collected by the RPM devices.
- Patient engagement
- Status quo: Patient engagement is a two-way street, both the practitioner and the patient need to be involved for it to be successful. However, challenges like time constraints, care complexity, and poor communication could affect patient activation.
- Ideal state with telehealth: Telehealth is an effective way to engage patients and help them increase their participation in the care process. Additionally, it’s a good way to involve caregivers as part of the process. Solutions like HRS’ CaregiverConnect® allows caregivers to monitor patient vitals including access to view patient adherence for each metric, as well as video and chat functionality.
Improve Population Health with Our Telehealth and RPM Solutions
An impactful population health strategy requires full commitment and understanding of the focus areas in order to execute the right plan for each. Learn more about how a telehealth solution can help with improving population health for your organization.