Central PA Travels to Texas for Population Health Discoveries

On September 19-20, more than 80 physicians, nurses, public health officials, care providers and more convened in Dallas, Texas, for Aligning Forces for Quality’s population health event, titled “Bridging the Gap between Healthcare and Population Health.”

A complex proposition, population health takes a broad approach to health care, working to deliver care wherever it needs to be delivered, preventing future health care needs and ensuring that the community, or population as a whole, becomes healthier.

Nadine Srouji, MD, FACP, medical director of quality for PinnacleHealth System noted the event’s value, saying, “It discussed how the health care system can participate and take a more active role in the health of the community, as opposed to just when people come into their offices and hospitals.”

Dr. Srouji participates as a key voice in Aligning Forces for Quality – South Central PA’s (AF4Q-SCPA) High Utilizer Learning Collaborative and was anxious to attend the event and learn from her peers around the country about how to translate good ideas into good practices. The panel discussion regarding high utilizers of care was of particular interest as these patients often face the biggest gaps in care.

“The system is broken for everyone, but for people who have other resources, not just financial resources, they can fill in the gaps. Many high utilizer patients can’t,” she said. “Because they have such complicated lives, when the system is broken it becomes evident in them sooner… By focusing on them, we aren’t only improving the system for them, but for the population in general.”

Unlike care systems of the past, population health addresses the issue that many of these gaps have little to do with medicine and more to do with social determinants. As Dr. Srouji sees it, within the current structure, patients come to the clinic for acute urgent care or chronic disease treatment – but a patient is not defined by his or her medical disease. There are many more contributing factors as to why patients aren’t getting the care that they need and aren’t becoming healthier.
“They could be non-responders to medications because they can’t afford it, they can’t get a ride to the doctors’ office or pharmacy, or maybe they can’t give themselves injections,” she said. “Once we start addressing those issues, we will be much more successful at [solving] medical issues as well.”

To achieve this success, Dr. Srouji also knows that it will take an interdisciplinary team approach – one that involves community leaders as well as clinicians. While in Texas, she was excited to learn about the work of Doug Eby’s Anchorage community, Nuka, an Alaska Native-owned and -run health safety net organization.

A few of Nuka’s best practices include embracing prenatal care as a three-year commitment. The organization sees each woman before she delivers and stays involved for three years, which is crucial for the health of the infant. Their care teams also are staffed with behaviorists who are skilled in examining social history and can uncover red flags and high-risk patients.
“Building better communities includes making healthier environments from infancy,” said Dr. Srouji. “The idea of expanding the ‘postnatal’ period to include a baby’s first years was a novel one to me.”

Among other innovations to implement, speakers also shared the effectiveness of community health dashboards that weave together state public health initiatives, as well as health care system goals.  By employing logic models, communities can determine which interventions make the most sense for their individual populations.

With these and many other great ideas learned, AF4Q-SCPA and its leaders are excited to implement plans that will increase community engagement and patient outreach and connect health outcomes with social determinants.

“There is no silver bullet when it comes to population health,” said Samantha Obeck, quality improvement coordinator for AF4Q-SCPA. “It will require collaboration and integration of health care sources along with community resources. Multiple interventions to address the health care needs of a community will require different payment models. Population health doesn’t happen within the walls of facilities, but rather where the people within a community live… By building ‘accountable care communities’ where everyone is involved, we can move the entire community forward.”

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