As communities build their population health infrastructure, one expert says small practice physicians are ideal partners to solve health issues.
According to a new report, small medical practices can play a major role in improving population health in the communities they serve.
Alison Rein, MS, senior director at AcademyHealth, a Washington, D.C.-based nonprofit organization dedicated to advancing the use of evidence in policy and practice, recently authored the report, published in partnership with the Office of the National Coordinator for Health IT (ONC).
The report, Toward Data-Driven, Cross-Sector, and Community-Led Transformation: An Environmental Scan of Select Programs, examined 17 programs across the country attempting to build the capacity at the community level to improve population health.
In her assessment, Rein said healthcare stakeholders are adjusting to “a tremendous period of change,” as they manage and make decisions toward advancing value-based payment models that require new initiatives designed to improve the way care is delivered and paid for.
In this era of healthcare transformation, small practice physicians, who want to participate in population health programs to receive payment incentives from health insurers, will have to account for the ways in which they have improved patient outcomes.
To accomplish this, they’ll have to redesign their practice from one that sees patients as individuals to one that broadens their concern to include social determinants that impact a patient’s health, such as paying attention to where they live, work and play.
“Small practice physicians can be very effective partners in helping to both identify and then figure out ways to address challenges that affect the health of the populations they serve,” Rein said.
Spotting social patterns
One example, Rein said, was that small practice physicians who see various patients from the same housing area can detect a larger problem. There is a very strong association between mold and moisture in housing, and the effect that it has on bronchial issues and asthma in both adults and pediatric patients, she said.
She noted that while the connection between housing and health can be noted by providers at the individual patient level, its recognition as a more systemic population health problem comes when multiple patients from a building or neighborhood repeatedly present with similar symptoms.
Rein said that if doctors ask the right questions and listen to patients’ answers, they’ll improve their ability to detect and remediate issues, such as finding out if the reason they didn’t get their medication is a function of affordability or lack of transportation to get to a pharmacy.
“To the extent that there are independent practices that are willing to ask the question ‘why?’ and carry that conversation forward, they’ll find a lot of opportunities to engage more meaningfully with their patients,” Rein said. “If they stop to see a pattern then it’s likely they will find a network of social or community-based agencies that are already working on a particular issue. I think there will be some organic partnership possibilities that will arise.”
Rein told Medical Economics that small practices that are looking to join a population health initiative should take away from the report that the 17 programs evaluated in the study have prioritized several goals that are the key to building a sound population health strategy.
The priorities include building the capacity to capture, share, integrate and use data, working toward eliminating socioeconomic, racial and ethnic health disparities as an integral part of the community’s chronic disease prevention and health promotion efforts, and the introduction of systematic processes that are changing care delivery, health systems and other social services to improve the quality of patient care.
Other priorities focused on leadership development to govern the use of data to guide major decisions, as well as expanding the geographic boundaries where populations share common characteristics, values and experiences.
“Building a population health program is not the kind of thing you can just do on the turn of a dime; it requires establishing trusted relationships, deploying a variety of resources, and a data infrastructure that can support meaningful analysis,” Rein said. “It also requires a general agreement about where you want to focus, what your priorities are, how you're going to achieve your goals, and identifying what governance structures are going to help you get there.”