“Right care, right time, right place”; this is the mantra of population health.The intent is to improve patient outcomes and control utilization, ultimately allowing patients to live their best life. For success, it requires seamless coordination across the entire care team, and a continuum creating an ensemble orchestration within the team.
Patients are often excluded from the care team. Nevertheless, they are expected to navigate the health system. Lacking guidance and core knowledge of the healthcare infrastructure, how would patients be expected to be successful? Historically, the provider relationship was a “prescribe and follow” method, where patients were told what to do with broad guidance but not provided the platform for success. For example, a patient would be instructed to reduce their body mass index (BMI) with limited tools and without any specific dietary coaching or referral to a nutritionist. This may be analogous to a football quarterback who is expected to make the right game time decisions without coaching, practice, and teamwork coordination. It would be very difficult to expect any quarterback to be successful in this type of environment without understanding the system and working with his team. As we drive population health to the future with digital health, decentralized health care, and consumerization, it is essential that the patient is set up with the proper toolkit and support network to be successful. The patient is the quarterback but they will need coaching, practice, and teammates to thrive. Over 99% of one’s healthcare decisions are made without subsequent follow up advice. From diet, exercise, meditation and work- life balance, patients should have control of these lifestyle decisions. This is why we need to help coordinate the proper pathway for the patient, to provide the relevant resources and healthcare personnel.
Personalized care plans with education and support systems would empower the patient to make the better healthcare decisions. Care team members must collaborate across domains to understand the unique conditions for each patient, to provide personalized coaching. This would enable the patients to manage their decisions to allow them to “call the right play and the right time”. Preventive health provides tools for a patient to maintain health and the ir quality of life. This should be the healthcare goal. Health maintenance requires the coordinated efforts across various care teams: education, self-service care, navigation, digital care in their home, biometric monitoring, and in person care amongst many other modalities. It is no longer just about capturing the data in the electronic health record (EHR) but about the utilization of artificial intelligence and data science to proactively provide actionable insights to the patient and care teams. The metrics should prompt care team members when the patient is off course, as well as engage the patient with targeted support to facilitate preventive care. With collaboration from the various disciplines, balanced healthcare decisions tailored to the patient would be prioritized. Healthcare journeys would be centered around their quarterback’s skill set, or in this case, the patient’s unique profile, and allowing them to thrive.
The target for this population health game is to empower patients to maximize their health potential as the quarterback of their bodies, build a trustful, supportive relationship,and foster collaboration with the healthcare team when in need. This would create health systems that are personal, proactive and progressive. The collaborative system is streamlined due to the inherent, bilateral trust and accountability. The individualized goals will enable patients to select tailored care. For one patient,that may mean getting back to being a competitive athlete.For another, it may be playing with their grandchildren.For others, it may just be successful ambulation.Population health requires personalized patient goals to create healthy, successful outcomes.
In addition to setting expectations and providing tools, creating a positive environment is important for the patient to stay engaged. Care teams should always celebrate patient achievements, support them through their hardships, but always be there for the patient in the present. Despite the wavering ups and downs, the patient will only be successful if they have the confidence and support from their team to maintain resiliency and perseverance. . This means being available for the patient’s needs. Treat the individual when they are sick, guide and educate the patient when they are lost, and provide the essential tools for the patient to interact with their care team. Patients need reassurance that their health is individually valued. Health systems must not only have a digital front door, but a coordinated hybrid interaction that supports the patient equally at home or on site.
Consumerization of healthcare is changing the patient profile. People are not satisfied with just being given instructions, but rather to understand the reasoning. Thus, they can be cognizant of the science and be partners in successful healthcare decisions. Those that understand their conditions can become engaged in proactive care. This would ultimately improve their best health decisions and allow them to take control of their health. When all patients feel empowered to control their own health with the support of their care team, population health will thrive.
