Engaging Patients through Population Health

As primary care physicians work through the mechanics of delivering population health, they’ll have to improve their ability to engage with their patients if they want to make these efforts a vital and profitable area of their practice.

Population health is advancing at a time when primary care physicians are transitioning from a fee-for-service payment model to a value-based system where they are paid based on the quality of care they provide.

In this new pay-for-performance platform, doctors who embark on population health initiatives will have to rely heavily on technology to help them stratify patients that need care the most, and develop new procedures to closely monitor their patients’ health to help them avoid the emergency room.

What this means, said David Nash, MD, MBA, dean of Jefferson College of Population Health at Thomas Jefferson University in Philadelphia, Pennsylvania, is that physicians will have to retrain themselves on new processes and procedures that they never learned in medical school.

“Population Health at the basic office level is a complete transformation from the way small practice physicians were trained in the systems and processes that they use every day,” Nash said.

Next: Boost patient engagement

Boost your patient engagement strategy

To help doctors embrace measures that will help them elevate their patient engagement strategy, Nash told Medical Economics there are four actions physicians can take:

• Utilize technology to build new patient engagement systems. Use emails, text messages, Skype video conference sessions, as well as their electronic health record systems (EHRs), billing systems data and other tools to track patient events. This includes everything from following up with adherence to medications and reminders to visit the doctor, to changes in medications that occurred during a recent emergency room visits or readmissions to the hospital.

• Know your patients’ preferences. Know what technology your patients will use, and what they’ll reject. An 85-year-old woman may not want to wear a Fitbit to track the number of steps she takes daily, but she will welcome a nurse practitioner to her home who can guide her through a daily exercise routine.

• Implement practices that vigorously engage patients during office visits. Talk to your medical staff about implementing procedures that closely monitor patients during their office visits. For example, diabetic patients that visit their doctor every six months should take their shoes and socks off automatically and their feet should be checked by a medical assistant to avoid future diabetic foot ulcers.

• Find out as much as you can about your patients. Improving patient engagement requires small practice physicians to learn more about the social determinants that impact the health of the group of patients they care for. This requires everything from knowing where they live and their level of education, to smoking status and if they live in a food desert. With this knowledge, doctors can better understand their patient’s health, communicate at a higher level, and tailor their services around patients’ needs. For example, appointments can be scheduled for an earlier time in the day if a patient lives in a neighborhood where it’s not safe to walk at night and the patient has to take three busses to get to the doctor’s office.

“Primary care doctors need to gain a deeper knowledge of the social determinants of health because one of the most important predictors of health isn’t your blood pressure or your heart rate, it’s your zip code,” Nash said. “By gathering population health intelligence doctors can make better patient engagement decisions to improve population health outcomes.”