Overview: Population health often focuses on a specific disease or a group of patients who have either chronic physical diseases, behavioral health issues, including substance abuse or social determinants of health. What if we looked at a population from a whole person health? What if we took a population with high risk and high needs based on their physical, behavioral and social determinants of health. Those populations in which the whole patient had extreme needs warranting significant resources, frequent and intense interventions and robust monitoring and management. It is this population for which this article is written. The highest need, highest risk, most vulnerable, often least engaged and for whom access is a continual challenge.
The Problem: How to manage high risk populations who have Behavioral, Social and Physical Medicine needs. The top 5% of patients often drive 35% to 40% of the total cost of patient care. One can debate why they are so costly, such high need and often, high utilizers, but it is often a result of poor access to primary care, reduced adherence and compliance, and a lack of meaningful engagement.
The Goal: Provide comprehensive care leveraging access to the PCP, support by an interdisciplinary team, care in the home and community and frequent touch points to monitor the patients while improving adherence to care plans.
The Solution: Several interventions have shown success and they include:
- Facilitated Virtual Care Visits: A more comprehensive telehealth visit in which the care specialist brings the technology into the home. The patient does not have to worry about technology. They have only one job: to be a patient. The facilitator, who is usually in the home, also manages the technology for the physician, allowing the physician to focus on the patient and just be a physician. The presence of the facilitator allows for a comprehensive exam in which lungs, heart and abdomen can be auscultated, visualization of the eyes, ears, nose and throat can occur. Vital signs can be taken and reported to the physician and documented in the EMR.
The facilitator should be an individual with whom the patient has a relationship of safety and trust. Their presence can help the patient relax, provide a more meaningful history of present illness and deriver more value from the encounter. The facilitator can also ensure the patient and patient’s family understand the care plan.
- Remote Patient Monitoring (RPM) and the use of Digital Equipment: Patients have exacerbations and medical needs between scheduled visits. Not all care can wait for the next visit. RPM and self-monitoring using digital equipment can alert the patient and provider to the need for an intervention between visits. Preventing a costly exacerbation improves the quality of life for the patient and helps pay for this service.
- Communication Between Visits: Even without RPM and digital equipment, a good old fashioned phone call (or text) can help maintain engagement and communication with the patient. For more technology savvy patients, mobile apps can provide this connection. It can enhance compliance and adherence, provide the patient another venue to communicate with the doctor or nurse, identify subjective findings (signs), and answer patient questions
- Integrative Care Models: These allow the PCP to manage behavioral health (BH) conditions within their patient population while leveraging support from the behavioral health specialist. The shortage of Behavioral Health professionals has put a strain on the US healthcare system, with poor access resulting in exacerbations and increased ED visits and admission. The new integrative care models, whether collaborative or consultative, allow the PCP and BH specialist to provide higher quality care to more patients. The improved quality and patient satisfaction is once again paid for by reduced ED visits and admissions.
- 7 x 24 care: Exacerbations, urgent and emergent care needs occur. Often at off hours during nights and weekends. Healthcare does not live by the 9 to 5 schedule. During these times, patients need access to care. We call this same day, next day, evening and weekend care. It can be a phone call, a video telehealth visit, a facilitated virtual care visit and finally a community paramedicine visit in the home. It may result in care and treatment in the field, a next day visit, an urgent care center visit or, when appropriate, an ED visit.
The outcomes: Reduced ED visits, admissions and utilization help pay for the increase services. The increased access improves quality of care, patient satisfaction and the quality of life for the patient. It improves patient engagement, leading to a better patient – physician relationship and improved self-care.
COVID-19: In the past 18 months, COVID-19 exposed and highlighted more vulnerable populations, with poor access, not served by health care systems. Healthcare responded with greatly expanded use of telehealth, increased communication to these populations and engaging known community health resources to open pathways, decreasing healthcare inequities.
The Future: We cannot return to traditional office visits for this vulnerable population. We must continue enhanced telehealth using facilitators in the home, remote patient monitoring, digital equipment and the use of simple healthcare tablets. We must deliver care where the patient is. This population, the highest risk, highest need and often least engaged, requires more touch points, more support and more intense services. Technology can help deliver this solution and the reduction in ED visits, admissions and utilization will help pay for it.