Getting to the Future of Population Health

Advice from Expert David Nash, M.D.
Health care organizations are reinventing themselves as population health takes hold. Five capabilities will be key to the transformation.

Few people have spent as much time thinking about value-based population health as David Nash, M.D., MBA, founding dean, Jefferson College of Population Health, Philadelphia. Internationally recognized as a population health expert, Nash has been teaching, writing and advising health care executives on the topic for decades.

Asked to sum up the field’s progress toward population health, Nash first focused on what he’s optimistic about: “Health care is beginning to recognize that social determinants of health are key drivers of health,” he said, referring to the impact that food insecurity, lack of transportation and other socio-economic factors have on health outcomes and costs.

By addressing these so-called upstream factors, organizations can better prevent and manage disease. Nash calls this “building a bridge” between providing health care and promoting health and wellness. “Leading organizations are focusing on going upstream to shut the faucet, rather than constantly trying to mop up the floor downstream,” Nash said.

However, Nash does not hold back on what he considers one of the biggest challenges. He believes a more rapid and full-scale shift to value-based payment is needed to change entrenched cultures and clinical practices and drive health care organizations to invest more time and resources in improving the health of their patient populations. “The faster we can get [financial] incentives aligned, the better off we’re going to be,” Nash said.

David Nash, M.D., MBA
Founding Dean
Jefferson College of Population Health

Key Capabilities

How can health care leaders prepare for the wide-scale adoption of value-based population health? Nash highlighted five capabilities that leading-edge organizations should address:

  1. Expand data analytics.
    Health care organizations need to work on improving their data analytics capabilities to more effectively evaluate patient populations, predicting which patients have the highest risk of hospital admission, poor health outcomes, etc. “This analytic capability is critical,” Nash said. “Without it, you cannot practice population-based care.”

    To accurately risk-stratify a population, health care organizations will need to collect non-health care data in addition to health-related data available from insurance claims and electronic health records. For instance, data related to social determinants of health can be pulled from publicly available sources or, in some cases, supplied by patients with their permission, Nash said.

    He is excited about the insights that organizations will be able to glean from a combination of health and non-health care data. “In the near term, I think we’ll be able to ask wonderful population-based questions. We’ll be able to say, ‘In these three ZIP codes, we have a large number of patients who get readmitted. What’s going on?’ or ‘In these three ZIP codes, we have a cluster of patients with out-of-control diabetes and multiple admissions. What’s going on?’”

  2. Invest in genetic screening.
    Nash sees precision medicine and population health as intertwined approaches for improving the health of both individual patients and populations. “Precision medicine — meaning I’ve got your genome and I can make certain predictions based on that — will help us practice population-based care much more efficiently and with a lot less waste.”

    For example, with genetic testing, physicians can determine which antidepressant or anti-clotting drug will work better for individual patients. Over time, as patients are matched to the most effective treatments for them, the health of an entire patient population will improve.

    Recognizing the revolutionary potential of genetic data, Jefferson Health in Philadelphia is piloting genetic testing with one population: its own employees. The health system, which includes Jefferson College of Population Health where Nash works, is offering voluntary genetic screening through Color Genomics to its 30,000 employees. The health system is covering the $285 per test cost, which includes a private meeting with a genetic counselor to discuss the results.

    More than 8,000 employees, including Nash, signed up to receive the testing this year. “The CEO of our entire system [Stephen K. Klasko, M.D.] decided it was worth it. Using this information, the genetic counselors will steer specific employees for additional screenings if, for example, they’re at high risk for breast cancer or colon cancer. It’s great linkage between precision medicine and population health.”

    To ensure employee privacy, the patient’s personal information is withheld. “My employer will not know what the genetic counselor is telling me,” Nash said.

  3. Improve patient engagement.
    To build a bridge from health care to health, providers need to start connecting with patients in their homes, workplaces and throughout the community. This might include connecting with patients online (e.g., email, texting, video conferencing and telemedicine), establishing clinics and practices in convenient locations, and spearheading or participating in community-based health initiatives.

    “It’s about engaging patients where they live and work, instead of making them come and fight for a parking spot downtown,” Nash said. “Our health system CEO likes to say, ‘Care everywhere.’ That’s what he wants Jefferson Health to be. For instance, if you want to talk to a doctor on a video conference at 2 in the morning, that’s care everywhere.”

    When prioritizing which patient population(s) to engage, Nash recommends giving precedence to patients with chronic diseases who have multiple admissions. “That’s one population definitely worth focusing on because we spend a lot of money on them,” he said. “And we could probably do a better job just coordinating their care.”

    Alternatively, large health care organizations might focus first on their own employees. “Big health systems that are self-insured are beginning to realize we have a kind of captive ACO made up of our own employees. Let’s first help them get healthy.”

    Significant cost savings may be achievable by managing employee health utilization. Research shows that health care employees tend to use more health services than their age-matched peers who don’t work in health care organizations, Nash said.

  4. Collaborate with community partners.
    To help patients who struggle with food insecurity, housing insecurity, loneliness and other social determinants of health, health care organizations need to partner with various community organizations and resources. Some hospitals and health systems have started screening patients to identify food insecurities or other socio-economic issues. These patients may then be referred to partner organizations that can help them obtain needed services and support, from housing assistance to ride-shared services.

    “For decades, social determinants of health were not really on our agenda,” Nash said. “But we’re starting to talk to the YMCA, the school districts, the churches, the synagogues, the community service organizations, the Kiwanis clubs and other organizations.”

  5. Train clinicians.
    Many physicians, nurses and other clinicians will need help making the shift from an episodic, acute care-based health care system to one focused on improving population health by preventing and managing disease. For instance, they may need training on when and how to screen patients for social determinants of health that are negatively impacting their health or ability to manage chronic diseases.

    Nash points to himself, a practicing primary care physician, as an example. “I’ve been in practice for more than 30 years and only recently have I started to ask patients questions like, ‘How many buses did you take to see me today?’ or ‘Is there food in your refrigerator?’ Like most doctors my age, I was never trained to do this.”

Case Studies

Improving the patient experience by making it easy to find and navigate hospital campuses

In recent years, Atlanta-based Piedmont Healthcare has grown rapidly. While the health system is now better able to serve patients, the addition of new buildings and campuses has made it more challenging for patients to find and navigate their way around Piedmont’s various locations and services. Recognizing that patients want health care organizations to provide a retail-like customer experience, Piedmont leaders partnered with Gozio Health to develop a smartphone app that makes traveling to and navigating around their buildings and campuses as easy and stress-free as possible.

“We want to capitalize on the growing reliance on smartphones for retrieving online information and directions. By employing Gozio’s powerful, innovative technology, our patients and families will feel confident in arriving at their destination anywhere in the Piedmont system,” says Matt Gove, chief consumer officer, Piedmont Healthcare.

The wayfinding app provides personalized step-by-step directions to any location in the Piedmont system. In addition to driving directions, the app helps patients find specific hospital services across the campus (e.g., admissions, cafeteria), as well as provides reminders of where they parked their cars. Plus, patients can access a physician directory, emergency department wait times, bill pay and many other features. Learn how Piedmont and Gozio Health first tested the app with employees before making improvements and rolling it out to patients.

“The demonstrated success of our mobile wayfinding platform helps to realize Piedmont’s mission of quality, safety and service. PiedmontNow offers patients transformational, next-generation access to medical services and a unified hassle free experience.” — Katie Logan, Vice President Experience, Piedmont Healthcare

West Baltimore Primary Care Access Collaborative, Bon Secours Baltimore Health System

As the result of a three-year, multifaceted Maryland state planning effort to address health-related challenges, the Maryland Community Health Resources Commission and Department of Health and Mental Hygiene has funded a four-year, $5 million Health Enterprise Zone initiative, the West Baltimore Primary Care Access Collaborative.

PASOs (STEPS), Greenville (S.C.) Health System

PASOs, which means steps in Spanish, works with the rapidly growing Latino population of South Carolina to promote health, education, advocacy and leadership development — all of which are steps to create a strong, healthy South Carolina. PASOs partners with health care and social service providers to help them provide more effective resources.

For more insights from the field, visit our Critical Topics Driving the Field directory.