An effective population health management strategy should take a holistic view of individuals and encourage behavior change in patients and citizens.
By understanding how the social determinants of health housing, transportation, health literacy, physical environment, access to healthy food, etc. affect an individual’s health and their ability to manage their care, care managers and their extended provider ecosystems can more effectively support care plans with lasting outcomes. Chronic disease management, for example, is not an activity confined to doctors’ offices and acute care centers, but needs to be realized in our communities and homes. With soaring health costs associated with treating chronic conditions, effective care planning that looks at the whole individual is required in value-based care settings.
An integrated care management solution can reflect this holistic perspective by augmenting the longitudinal patient record often based on clinical and claims data with geographic datasets reflecting social, behavioral, and environmental factors. These richer datasets can, in turn, feed predictive models to produce more nuanced cohorts that can be referred into better-targeted managed care. Care plan assessments can validate the presence of specific social determinants, and corresponding actions can identify community-based social services homecare, housing services, transportation services, nutritional services, etc. Care plan monitoring can oversee how both clinical and social interventions work together. The IBM Watson Care Manager solution can be used to explore this approach.
By leveraging broader determinants of health throughout the population health management process, there is a stronger likelihood of improving population health outcomes, such as better plan adherence, engaged patients, and fewer readmissions.