by Wendy Bartlett / February 19, 2019

Addressing Social Determinants of Health: See How at CPCA’s Quality Care Conference

InteliChart will be at the California Primary Care Association (CPCA) Quality Care Conference to show health center staff in attendance how to address Social Determinants of Health (SDOH) with population health management technology. The conference is being held February 21-22 in Santa Rosa, CA.

SDOH is a CPCA priority and a major factor in improving the health status of low-income, uninsured and underserved Californians. According to Healthy People 2020, a national science-based effort for improving the health of all Americans, SDOH are conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes. About 40% of a person’s health is attributed to social factors such as social determinants of health.1 To fully care for their patients, CPCA health centers are understanding the need to learn about the social determinants of health affecting their patients.

To that end, CPCA is taking part in the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE), a national effort to assist health centers and other providers in collecting data needed to better understand and act on their patients’ SDOH. CPCA is currently working with the National Association of Community Health Centers (NACHC) and other national partners to finalize Phase One of a pilot program in California with four consortia and eight health centers using the PRAPARE tool.2

Income Significantly Affects Health
One study – Looking at Social Determinants of Health in the U.S. and Comparable Countries – found income can significantly influence health outcomes and that people who have lower incomes are less likely than those with higher incomes to report being in good health. The study further concluded there is a growing disparity in the life expectancies of low- and high-income Americans.

Also included in the study was data on behavior and lifestyle-related social determinants of health, citing that the U.S. has the highest prevalence of obesity and insufficient physical activity among adults compared to other high-income countries. Furthermore, the World Health Organization quantified the effect of environmental factors, such as pollution, occupational risks, agricultural methods, climate change, and food contamination and taken together, these factors present a higher burden of disease in the U.S. than in comparable countries.3

Add to the mix that 5% of the population – those with two or more chronic conditions – account for 45% of all healthcare spending,4 and it’s clear that clinics face an undeniable challenge in keeping their patients healthy.

Enter: Population Health Management Technology
CPCA’s membership is comprised of urban and rural clinics, federally funded clinics and clinics dedicated to special needs and special populations. Between social determinants, poly-chronic patients, and minimal resources, how can clinics like these effectively manage population health while also keeping an eye on value-based care reimbursement? With population health management technology that streamlines data, conducts analysis, automates outreach, elevates outcomes, and improves MIPS performance.

Clinical and claims data aggregated from a health center’s electronic health record (EHR) are the foundation of these technologies. From this baseline, providers can incorporate other crucial data into their analysis, such as these social determinants:

Physical environment. Air and water quality; housing type, access to transportation and proximity to grocery stores.
Behavioral. Diet, exercise, tobacco- and drug-use; stress, adherence history information, and metrics on estimated likelihood to modify behavior.
Social. Education level, literacy, employment, income, financial history, neighborhood, and highly granular data such as the distance away from the closest relatives.

Armed with these rich datasets, clinics can stratify patients into risk categories, such as chronic-condition populations, and identify highest-risk patients who need interventions. Population health management technology reduces labor-intensive data searching and patient communication with lower-risk patients so care managers can focus more of their limited time on higher-risk patients to help them overcome care plan adherence obstacles.

It’s also important to note that a providers’ ability to manage populations across all risk profiles is key to success with MIPS or any value-based care payment program. After all, today’s moderate-risk patient can be tomorrow’s high-risk patient.

Manage 2-3 Times More Patients with Automated Outreach Campaigns
A clinic tracking diabetic patients, for example, can establish rules within the population health management platform to automatically contact patients through multiple modes such as phone, text, postal letter, or through a patient portal. The notifications send an alert when patients should take a certain medication, have not scheduled a maintenance appointment, or forget to fulfill self-management tasks such as recording home blood pressure readings or glucose monitoring.

Multiple campaigns can be combined for a more comprehensive automated analysis and outreach effort. Regardless, organizations must only create the campaigns one time and the platform will automatically search the updated patient populations for at-risk patients.

As a result of automated interventions, health centers can manage two to three times more patients using seven to 10 touchpoints without giving more work to already overburdened clinic staff. A study of text message medication reminders found it doubled the likelihood of adherence to regimens, affirming the efficacy of technology-assisted interventions. Plus, consistent and relevant outreach and communication yield strong engagement from patients who feel more connected to providers demonstrating concern about their health throughout the year.

HealthyOUTCOMES®: The Platform for Engagement to Outcomes
PopulationHEALTH – one solution in InteliChart’s HealthyOUTCOMES® suite – empowers clinics to tackle population health management head-on. This powerful solution acquires and aggregates patient data from a single source or multiple systems using one API platform. The tool establishes intervention goals, creates automated campaigns, and helps attain outcome goals.

Additional solutions in the HealthyOUTCOMES® suite include:
PatientPORTAL – 2015 MU3 Certified, satisfies MIPS requirements, integrates seamlessly with acute and ambulatory EHRs, and aggregates data into the HealthyOUTCOMES® clinical registry so that patients can see all their data in a single portal.
PatientSURVEY – automates delivery for patient satisfaction surveys and patient-reported outcomes.
PatientNOTIFY – eliminates workflow inefficiencies by automating patient communications.
PatientINTAKE – creates a consistent intake process for patients that increases portal adoption and streamlines the check-in workflow.

HealthyOUTCOMES® helps health centers:
• Maximize reimbursement
• Reduce no-shows
• Streamline staff efficiency
• Achieve outcomes goals

See HealthyOUTCOMES® at CPCA’s Quality Care Conference, Booth #14
We are excited to showcase the power of our HealthyOUTCOMES® platform at CPCA’s Quality Care Conference, and welcome providers to visit booth #14 to see how automating population health management with our PopulationHEALTH solution enables clinics to perform at an optimal level for patient engagement and quality performance needs. Providers will also see first-hand the advantage of working with a single vendor for multiple solutions, the ease of one integration, and the efficiency of data from all sources syncing back to a clinic’s EHR. Click here to sign up for a demo and receive a $25 gift card!

About CPCA
Representing more than 1,300 not-for-profit Community Health Centers and Regional Clinic Associations, CPCA is a key player in the healthcare delivery system. The Association leads and positions community clinics, health centers, and networks through advocacy, education and services with a focus on improving the health status of their communities, particularly low-income, uninsured and underserved Californians, who might otherwise not have access to health care.

1 https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
2 http://www.nachc.org/research-and-data/prapare/
3 https://www.healthsystemtracker.org/brief/a-comparison-of-social-determinants-in-the-u-s-and-comparable-countries/#item-start
4 https://www.oliverwyman.com/our-expertise/insights/2012/nov/the-volume-to-value-revolution.html