As a physician, I have treated my share of “noncompliant” patients. These patients tend to ignore recommended screenings and tests, whether due to other obligations and priorities or for other reasons.
Josephine was one such noncompliant patient. She had diabetes and a long list of screenings that needed to happen. As an African-American, middle-aged woman, Josephine was among our most at-risk patients whom we knew we needed to see and get into the clinic. Yet the usual postcard reminders and daytime phone calls went unanswered.
There are hundreds of Josephines in today’s healthcare landscape—high-risk patients whom we struggle to cut through the noise of everyday life and reach in this new age of population health management. Our best efforts didn’t seem to be enough in Josephine’s case, but then a care manager went the extra mile.
She called Josephine at home, around 7:30 p.m. It turns out Josephine was like everybody else—going full speed while caring for her chronically ill mother, raising her family, and working full time.
Having made this personal connection, the care manager was able to help Josephine get back on track. Josephine began properly managing her diabetes and receiving the tests she needed. She also received a long-overdue mammogram from an easy-to-deal-with walk-in provider. The screening showed she had early-stage breast cancer.
Applying Population Health Management
Population health management, the art and science of caring for patient populations while still allowing primary care physicians to care for patients as individuals, can be boiled down to simply identifying new ways of successfully engaging patients. So what really happened in Josephine’s case? What can we learn?
Population health management is not just about managing a population. It’s a way to identify patients who need one-on-one care but have not been actively engaged in their care. For providers, especially in today’s challenging payment environment, this is where leadership becomes vital.
First and foremost, physicians themselves must be engaged. They must be incentivized and rewarded for participating fully in a population health management program.
Physicians also must have data upon which to base decisions. Without data they are working in the dark, with no idea which patients need them the most and thus how to prioritize resources and manage work flows. The data must be in an actionable and easy-to-understand format; otherwise precious time is spent, often by multiple staff members, trying to determine the best course of action.
Lastly, the team leveraging the physicians’ expertise and allowing them to practice at the top of their license must be organized and trained.
Once these three elements are in place, the focus can shift to actual patient engagement.
The importance of patient engagement cannot be understated. Patients should not be considered “noncompliant.” Rather, we need to think of them as having priorities we do not share or understand, and until we acknowledge this fact and figure out a way to meet them on mutual grounds, we will not be successful.
Thinking Like a Patient
How can we engage our patients and encourage them to partner with us in their care? First, we need to put ourselves in their shoes. All of us surely have put off a scheduled or recommended healthcare screening, dental exam, or the like due to a work- or family-related conflict. That’s why convenience for patients is key, as it was in the case of Josephine, for whom simply discovering that she could “walk in” for a mammogram was enough to encourage her to go.
Think about communication tools that make sense for your populations. For example, trying to roll out a text message-based communication plan will likely have more success in a commercially insured population compared with a Medicare group. That said, patient portals that facilitate two-way communication between patients and providers can be appropriate for all populations.
To encourage patients and providers to be real partners in their care, patient engagement initiatives must be coupled with robust resource and service choices. The role of hospital leadership is to actively encourage co-management specialty service expectations. Without this level of commitment, primary care is not as effective in moving the needle on population health.
Primary care practices must have a clear path to refer their patients for specialty care. These specialty providers may be within or external to the organization. If specialty access is not available in-network, then leadership should forge the relationships necessary to establish out-of-network access. These efforts may promote true cross-disciplinary collaboration that will help the system evolve while fostering business success. Examples include enhanced radiology access for mammography, at-home colorectal cancer screening initiatives with gastroenterology follow-up for colonoscopy, and education provided by endocrinology to help primary care physicians manage difficult diabetes cases.
Engaging Patients, Improving Outcomes
Returning to the story of Josephine, she is doing very well. She received timely treatment for her breast cancer, her diabetes is in check, and she even received a colonoscopy. She was able to continue with full-time employment because services were conveniently available when she needed them.
Her care manager connects with her routinely—sometimes just by text. And her primary care physician has remained at the center of her care team, with Josephine as a full-time partner. Her case shows how by achieving true patient engagement, outcomes can be improved across the board.
Dorothy Y. Fisher, MD, MGH, is chief clinical officer, Forward Health Group, Madison, Wis.