Population health management has been gaining a lot of traction in recent years, as health systems work to prevent disease and improve access to care for large groups of patients – all while reining in costs while improving quality outcomes.

Quite a number of health IT companies have popped up to serve the pop health market. Often integrating with electronic health records, these systems help clinicians and researchers better manage care plans and boost engagement for patients with chronic conditions.

Greg Silence is executive vice president and co-founder of AssureCare, which develops technology to unify payers, providers and pharmacies to deliver patient-centric care. Greg has more than 25 years of experience in care coordination and population health.

Healthcare IT News sat down with Greg to talk about recent developments in pop health IT, how pop health may evolve this year, connecting existing community/social services to patient needs, and the pharmacy's role in population health management.

Q. What are some recent  technology developments playing a major role in advancing pop health today?

A. Population health management is most commonly defined as the process of improving clinical health outcomes of a defined group of individuals through improved care coordination and patient engagement supported by appropriate financial and care models.

Population health management has come to the forefront as a key driver of value-based care success. Organizations that can deliver population health well are more likely to see the positive outcomes that yield an effective value-based care model.

As the healthcare industry pushes toward reimbursement models that emphasize value and outcomes, it has recognized the role the patient and the health of populations will have in achieving key outcomes. Organizations that leverage patient motivation, expand patient access to care, and provide community-based resources that account for social determinants of health can be successful in improving outcomes via population health management programs.

One of the biggest drivers in population health is consumerism. Patients are rightfully demanding accessibility and affordability in their care. Technology solutions have historically been provider-centric.

We need to shift the mindset in developing patient-centric technology solutions that follow the patient across the healthcare ecosystem and help meet consumers' demands for affordability and accessibility.

Real-time information exchange – such as via wearable devices – is making a powerful and positive impact on population health; however, there is still work to be done to fully leverage this data for monitoring patient populations.

Companies like Apple have been investing heavily to advance capabilities in products, such as the watch, to provide real-time notifications to providers and patients with important information to better manage their health. One example is information concerning heart health where wearable devices can provide heart rate notifications, irregular rhythm notifications, etc. Another example is fall detection and the associated alerts to emergency services.

Q. How do you see pop health IT evolving in 2022?

A. First, let me speak to the evolution in population health management to date. As we begin 2022, the health and wellness of our loved ones, friends and communities is certainly top-of-mind for us all.

To say that the past two years have been challenging is an enormous understatement. As I reflect on the impact of the COVID-19 pandemic on our physical and mental health, the focus on population health management becomes even more important.

The perception may be that population health management is a relatively new trend, but it has been a fundamental component of the U.S. healthcare industry for years. In my more than 25 years in the industry, I have seen population health management evolve as a significant part of many different initiatives.

The following drivers have influenced this evolution.

First, integration of the commercial and public sectors. In the United States and U.S. territories, two prominent groups are responsible for the payment of healthcare services. The commercial sector includes insurance companies such as Aetna, Cigna, the Blue Cross Blue Shield companies and many others.

Then there is the public sector, which offers and funds government-sponsored healthcare programs. These two sectors were historically divided operationally until the signing of the 2010 Affordable Care Act. ACA catalyzed the breaking down of the walls between the public and private sectors, leading to an increase in healthcare coverage and access to care – both essential to achieving the goals of the Institute of Healthcare Improvement Triple Aim.

Second, the impact of HCBS, LTSS Programs. Home and Community-Based Services (HCBS) and Long-Term Services and Supports (LTSS) programs are critical to population health management initiatives to help keep patients independent and in their home. These programs are designed to improve people's lives by offering a range of services that are crucial to managing chronic diseases – medication management, healthy eating habits, basic needs and more.

Third, the transition from fee-for-service to value-based care. The traditional fee-for-service reimbursement model focused on quantity of services, whereas the newer approach of value-based care focuses on quality of services and patient care. This patient-centric, outcomes-driven model is a key driver in population health management, and ensuring that your technology enables patient engagement solutions is critical.

Fourth, staying ahead of the curve and continuing evolution in 2022. Healthcare and supporting healthcare information technology are constantly advancing. Telehealth, patient engagement and wellness initiatives – and access to a rapidly evolving set of mobile devices and wearables – are just a few of the drivers that are improving population health management today.

The healthcare industry, including payers, providers and pharmacists must be committed to a proactive approach. As I mentioned, the COVID-19 pandemic placed a tremendous burden on the healthcare system. It is more important than ever to keep our communities healthy through targeted and effective population health management initiatives.

Additionally, the future of population health must leverage technology solutions that are designed to manage and proactively trigger actions based on the patient's unique social determinants of health. In addition, macrotrends – such as longevity of life and multiple chronic conditions – and their impact in coordinating care must be incorporated into population health technology solutions.

Lastly, incorporating pharmacogenomics data into health IT solutions is an area I expect to continue to evolve and play a major role in advancing population health management and improving health outcomes.

Q. What is one example of some of your experience in using technology to connect existing community/social services to patient needs? And why is this connection so vital to improving health in communities?

A. An AssureCare client, one of the largest health insurers in the U.S., launched a community care program in 2018 to address the behavioral and social factors that contribute to serious illness – and drive up healthcare costs. Central to the program are local care managers who are embedded in the communities they serve. AssureCare implemented the care management technology platform supporting this program.

The community care program used by the client is a program that employs nurse care managers, social workers and health educators who live close to residents and understand their communities. They meet people face-to-face in their homes, shifting the conversation from the exam table to the kitchen table.

If a doctor observes that a treatment isn't working, the local nurse care manager can follow up, getting to know the person in their environment to learn why the treatment isn't providing the expected results.

Each local pod is supported by a multidisciplinary team of pharmacists, registered dietitians and mental health specialists who work with the care manager to address needs holistically across medical, social, financial and emotional spectrums. The team coordinates closely with physicians to support a customized treatment plan for the individual and caregivers.

People are afforded more frequent and convenient contact with their doctors and nurse care managers, even from a distance. They are able to check in with their doctors or care managers quickly and remotely – without having to travel or take time off from work for an appointment every few months. These advances have the added benefit of reducing healthcare costs.

Empowering local personal care teams to address not only the health needs but also the social needs of patients is the key to better outcomes for both patients and their families.

This approach, along with connecting patients with community resources that help to address some of the barriers to successful care, is a powerful formula for improved clinical quality and quality of life. For example, if a man is feeling depressed or isolated following a diagnosis of prostate cancer, the nurse care manager can connect him with a therapist or support group.

The technology platform provides a comprehensive care management suite of functionality that fully enables the client's community care model of care. The solution has been installed on the Windows, Apple and Android-powered devices like phones, tablets and laptops that the nurse care managers, social workers and health educators would use while visiting patients face to face.

The solution has the ability to access and store the information based on the interaction with the member and the data can be captured during the member's assessment even in settings where internet connection is not available to the care team member.

Additionally, the platform features, like automated business workflows, enable the care team to follow up and connect with patients when certain health conditions or data points – for example, changes in cholesterol levels, blood sugar level, etc. – are observed.

The care team recommends preliminary care such as diet or lifestyle changes to control the condition and will also refer to the nearest available care facilities should the condition need urgent treatment. The video chat capability in the application enables virtual meetings; this has been a great resource that allows people to stay at home and still receive the care they need. The feature has been increasingly utilized since the COVID-19 pandemic began.

To further enhance the community care program, the solution is integrated with the client's community resource directory using an application programming interface. This enables a real-time lookup for the most recent community resources – such as food, home health, health education, vaccines, transportation, health and mental health services, etc. – available nearest to the member and provides recommendations based on the member's needs.

This technology has played a crucial role in greatly advancing the client's population health management initiatives to generate better health outcomes and help keep patients independent and in their home.

Q. What is the pharmacy's role in population health management? And how does health IT fit here?

A. Pharmacists are uniquely positioned to support population health management as highly trained, accessible and trusted healthcare providers. With 90% of Americans living within five miles of a pharmacy, it goes to the reason the public would benefit from expanded healthcare services from their local pharmacy.

We see this benefit today as pharmacies play a major role in COVID testing, vaccination and education efforts. It is the most recent example of the impact pharmacies have as they take a more active role in consumer-driven healthcare and population health management, but it is only the tip of the iceberg.

The positive impact of pharmacy-driven healthcare services such as medication management, adherence support and disease management for high-risk populations has also been demonstrated and is recognized by the healthcare community and payers alike.

The success of pharmacies in this larger role, however, is predicated on their ability to access vital patient information, efficiently document clinical work, and effectively outreach patients, providers and payers. Pharmacies often lack technology capable of supporting this and struggle with challenges inherent to the disconnection of healthcare and pharmacy technology. This stifles the full potential of population health outcomes.

Leveraging technology to create a more cohesive ecosystem that effectively connects the pharmacy with patients, payers and providers would dramatically reduce barriers to improving care. Taking that a step further, with technology that can analyze that data to identify and stratify patients by risk factors to proactively address health-related barriers before they become catastrophic, would allow pharmacists to better serve as true safety nets for patient care.

When pharmacies have visibility to patient health data and insights into potential clinical opportunities, they can become highly effective members of the healthcare team. Given the right technology and interoperability, pharmacists can further their role as a touchstone of the medical community.

Serving as a provider extender, offering vital health screening services for payers and proactively managing medications are all on the table. Population health could truly see a transformation once this profession is able to fully engage as a connected member of the healthcare team.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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