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Benefits of blending population health and hyper-local health barrier strategies to address SDOH


Physicians can improve patient outcomes, accountability, and the financial bottom line through a hybrid focus on social determinants of health.

physician doctor patient in medical office: © sebra - stock.adobe.com

© sebra - stock.adobe.com

In 2024, accountable care organizations (ACOs) will have to demonstrate the efficacy of their health equity plans. Many ACOs have implemented strategies already with this goal in mind. Traditionally, ACOs have had their primary care physicians focus on population health management: addressing broad health trends and risk factors across a patient base. However, an approach that also focuses on personalized solutions offers primary care physicians the opportunity to truly improve patient health outcomes in a measurable way. ACOs can ultimately see the efficacy of such a strategy in both improved patient health outcomes as well as their return on investment (ROI).

Towards this end, risk-bearing organizations and their primary care physicians can shift their outlook on social determinants of health (SDOH) from a population health view to a health barrier perspective approach, which delves into individual-level root causes. When used in conjunction, strategies that address both population health, as well as individual barriers, can really play a key role in improving health outcomes for communities and driving health equity.

Population health view

Hillit Meidar-Alfi, PhD 
Spatially Health

Hillit Meidar-Alfi, PhD
Spatially Health

Historically, health systems, health plans, and risk-bearing organizations – including ACOs – have taken a population health approach to tackle SDOH. This approach involves looking at data at a broader level to identify trends and commonalities within a population and then developing interventions that target the most prevalent issues, such as those at risk for cardiovascular disease or diabetes. While this approach has yielded some positive results, it can fall short in terms of successfully addressing the unique and individualized barriers that people face.

Further, population health strategies typically focus on implementing large-scale interventions, such as public health campaigns, community programs, and policy changes, which aim to improve the overall health of a population. For example, such efforts can help address widespread health issues, including smoking, obesity, and infectious diseases. However, when it comes to the root causes of health disparities, especially those that affect vulnerable and marginalized populations, adding a hyper-local approach can improve the efficacy of the strategies both in terms of patient health outcomes and improved ROI for the risk-bearing organization.

Shifting to a personalized health barrier perspective

An individualized health barrier perspective involves addressing SDOH from a hyper-local angle, capable of identifying and treating individual-level root causes. This approach recognizes that each person may face unique barriers to achieving good health and that a one-size-fits-none solution will not likely garner improved patient health outcomes nor raised ROI. By shifting the focus from a population health view to a health barrier perspective, ACOs can better serve their patients and communities. Such a personalized approach fosters actionable and impactful results by enabling providers and care managers to tailor interventions to the specific needs of each patient. It ensures that resources and efforts are directed where they will make the most significant difference, leading to more efficient and effective care.

Moreover, focusing on individual-level root causes empowers patients to actively participate in their own health improvement journey, increasing the likelihood of compliance and long-term positive outcomes. This precision in health care delivery can not only improve patient health but also contribute to cost savings and enhanced ROI. However, if risk-bearing organizations move to only a hyper-local approach, they might not see as many benefits as they could with a hybrid one.

Hybrid of localized solutions and population health

The shift from population health to the health barrier perspective does not require abandoning one view for the other. In particular, adopting a more balanced approach that harnesses the strengths of both can have profound benefits for both improved patient health outcomes as well as ROI.

  1. Targeted interventions: A population health view can identify broad trends and disparities that need attention, such as high rates of diabetes in a particular community. Complementing this approach, a personalized health barrier perspective can determine why some individuals within that community struggle with diabetes management. This lens enables risk-bearing organizations to tailor interventions for those individuals, addressing their unique barriers, such as: limited access to healthy food, lack of transportation, or low health literacy.
  2. Individualized care plans: Population health data can help ACOs develop guidelines and best practices. Further, by incorporating strategies from a personalized health barrier perspective, these organizations can further support their patients. By understanding the specific challenges faced by each individual, ACOs can create care plans that are more likely to lead to improved outcomes.
  3. Preventive medicine: Population health identifies groups at higher risk for certain diseases. By also considering the personalized health barrier perspective, these groups can pinpoint which individuals are most vulnerable and why. Such information enables ACOs and care managers to engage in proactive outreach, offering targeted preventive measures to those who need them most.
  4. Health equity: The health barrier perspective helps ACOs address health disparities by focusing on the root causes of these inequities at the individual level. By identifying and mitigating these barriers, ACOs can contribute to greater health equity within their patient populations.

To improve health outcomes and drive health equity, risk-bearing organizations can shift their perspective on social determinants of health to include both population health and hyper-localized strategies. Leveraging strategies from both perspectives is complementary and empowers ACOs to provide the highest quality of care to individuals throughout their patient populations. In the end, ACOs can measure the success of such endeavors through improved health outcomes and ROI. Doing so will deliver truly accountable and patient-centered care.

Hillit Meidar-Alfi, PhD, is the CEO and Founder of Spatially Health, a company that offers dynamic, customized SDoH analytics tech to ACOs. Complementing her expertise in spatial analytics, Dr. Meidar-Alfi has a background in city planning and architecture.

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