Population Health

Lama El Zein MD, MHA
Former Sr. Medical Director, Population Health & Clinician Engagement

Healthy Aging

Healthy Aging Month has been celebrated in September since 1992. It has triggered many initiatives to help people live longer, healthier lives. This has meant that people have had the opportunity to plan for more milestones that bring joy and excitement — graduations, marriages, starting families, and embarking on new careers.

Longer lives can mean health challenges as well. Living life the way we want it to be, in sickness and health, is crucial. And yet, advance care planning is often overlooked, despite it being as important as the milestones in our lives. Advance care planning allows individuals to make informed decisions about their own medical treatments and end-of-life preferences while they still have full capacity to do so. While it’s important on an individual level, this patient-centric type of care is at the basis of a strong population health strategy.

Your role as clinician

Thinking about our own mortality and potential future incapacity can be very uncomfortable. Yet, as clinicians we need to ask our patients to confront these difficult subjects, and to make decisions, document them, and be sure we have copies of any decisions in their medical records.

As clinicians, you can play a pivotal role in facilitating advance care planning. You can start the conversation at any office visit, but most appropriately during the annual wellness visit or when a new diagnosis arises.

Advance care planning is a separately billable service for all of our member’s plans and may be subject to a member’s cost-share. For our Medicare members, review our Preventive Services reimbursement policies (EmblemHealth | ConnectiCare) to see when cost-share waivers apply.

To make the most of your discussions, actively listen to your patient’s concerns and offer support throughout the process. You are the patient’s advocate when it comes to respecting their preferences. Here are some tips for having advance care planning discussions:

If you have the option, consider whether the exam room or your office is the better location to address the topic. Ask permission to start the conversation.
Assess what the patient and family already understand about their health challenges and diseases they need to manage so you can fill in the gaps.
Be empathetic; speak in simple language using short sentences, especially when giving updates or a prognosis about a disease or condition.
Take breaks and allow for silence so they can process what is being said. Remember, this may be a daunting experience for them.
Ask about the patient’s and family’s goals, fears, challenges, and the barriers they are worried about.
Ask for questions and feedback.
Briefly summarize the discussion and set specific recommendations about their next steps.

We recommend encouraging your patients to initiate planning discussions with their family and/or friends while they are still able to make decisions and define their needs and wants regarding their futures. The U.S. Department of Health & Human Services’ National Institute on Aging has a comprehensive conversation guide you can share with your patients. It will explain their options for documenting their wishes, from a simple health care proxy to a living will or more detailed medical orders for life-sustaining treatment (MOLST).

See more resources available to you and our members on our new MD Perspective Programs, Classes, and Resources page.

Pride Month

The LGBTQ+ community is a population that comes from different races, ethnicities, and cultures.

From a population health perspective, we see that being part of the LGBTQ+ community correlates with higher disparities in health care. As part of our National Committee for Quality Assurance (NCQA) health equity accreditation, we are collecting data around sexual orientation and gender identity. Having this information helps us:

Design better clinical assessments.
Uncover more barriers to care.
Better address gaps in care.
Enhance the programs we offer (e.g., HIV/AIDS care management).
Improve the overall health of our members.

The road to health care equity is a long one, but every step we take gets us closer to this goal. As we gather information and run analytics, we are also working to build an internal culture that supports the LGBTQ+ community.

We have our own employee resource group, Prism, for members and friends of the LGBTQ+ community, who will lead the celebrations of Pride Day and National Coming Out Day for our companies. The group is working with community-based groups during Pride Month to bring awareness of health issues affecting the LGBTQ+ population. Prism undertakes education and training efforts to create better experiences for employees and the members we serve. In addition, the group is looking to launch the LGBTQ+ Healthcare Coalition and collaborate on LGBTQ+ health initiatives with other organizations across the region.

In our efforts to meet our members where they are, we and our teams take cultural competency training. This training includes education around the LGBTQ+ population as well as the larger communities they are part of. We believe this training is critical for those who work directly with our members. We also invest in learning to be mindful of our own implicit biases so we can make better decisions and offer better support to our members.

To help you learn about the LBGTQ+ community, we have a free online training that we encourage you to review.

Our Three-Pronged Approach to Social Determinants of Health (SDOH)

Addressing social determinants of health (SDOH) is complex and needs a delicate approach. Given the complexity of the topic, we understand that practices cannot address everything. Even so, we should all start somewhere. See how we can help you. Our three-pronged approach to SDOH is to listen to members by collecting information, identifying the barriers to good health, and proposing reliable solutions.

Listen to Members and Collect Information

The first prong is listening to our members. We collect information by asking our members directly what they need or struggle with. We do this through a range of assessments conducted by paper, online, telephonic, and in-person surveys. We also look to you, our clinicians, to screen your patients by using recommended screening tools. We need you to join us in identifying what your patients need. National Committee for Quality Assurance (NCQA) has adopted a Healthcare Effectiveness Data and Information Set (HEDIS) measure for SDOH. Here are some tools that may help you to integrate the measure into your Electronic Medical Record.

The American Academy of Family Physicians (AAFP) Social Needs Screening Tool
The Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool
Free Webinar - Don’t Be Fooled . . . Social Determinants of Health are Key Factors for Your Patient Population April 25 and April 27, 2023, at 8:30 a.m. and 12:30 p.m. offered by Veradigm (formerly Pulse8) as part of EmblemHealth’s Risk Adjustment Program.

As you know, the most useful and actionable information comes when the patient feels that they are really being listened to. It begins with being sensitive to what the person is telling us and learning how to understand their meaning in the context of that person’s culture, language, and background.

Within our own family of companies, we are training ourselves to be more sensitive to our members’ needs. We are bringing on more staff with active listening skills. This includes our care managers, our social workers, and our EmblemHealth Neighborhood Care and ConnectiCare Centers community staff who can both actively listen and help find solutions. We look forward to working with your practices to enhance the recognition of SDOH factors.

Identify the Barrier

The second prong, identifying the barrier, is another way of saying that we look for the patterns that affect health. Helping our patients understand their own barriers and their relationship to health outcomes is crucial. From the screenings and active listening mentioned above, you will be able to identify the SDOH factors that are affecting the patient’s health.

On a population health level, it is important to understand the community we serve. This is why it is crucial to look at those screening questionnaires in the context of the community’s overall needs and challenges.

As medical directors in a health plan, we have an incredible amount of data based on claims, preauthorization requests, and referrals. We can, for example, look at a set of diagnoses and compare them to the demographic information we have for our members. The top three barriers and areas of concern we usually see are:

Transportation
Food insecurity
Housing

Identify Reliable Solutions

The third prong is identifying reliable solutions. Once a patient agrees to follow up on an identified SDOH barrier, we can help you connect them with resources to assist them. If you do not have the resources to address SDOH within your practice, you can always refer to our Care/Case Management Programs* or  EmblemHealth Neighborhood Care and ConnectiCare Centers.

We have staff dedicated to brokering and supporting personalized Care Plans for our members through our Care/Case Management Programs*. We welcome your referrals to these programs. Make sure to check the Member Eligibility page on our provider portal to see if your new patients have a Care Plan in place (EmblemHealth | ConnectiCare).

When we at EmblemHealth and ConnectiCare suspect a barrier may be in place, we may partner with our EmblemHealth Neighborhood Care and ConnectiCare Centers. They can conduct an in-person assessment and help members navigate through potential solutions. Our EmblemHealth Neighborhood Care and ConnectiCare Centers are open to everyone in the community. They offer classes such as healthy eating and meal-planning to teach nutrition, exercise classes, and much more. They host pantry events to help those who need healthy food. They can connect your patient to services offered by various organizations and government agencies.

Our plans also sponsor community events. We partner with community-based organizations to provide local help. This allows us to provide interventions in neighborhoods where we do not have permanent centers.

Overall, the journey to address SDOH is still in its beginning. We need to take a moment, slow down, ask questions, and listen to our patients and members.

*Care/Case Management Programs

EmblemHealth: See our Care/Case Management Programs page for program descriptions, ways we can support you and your patients, and program-specific contact information. If you need general assistance, you can call 800-447-0768 Monday through Friday from 9 a.m. to 5 p.m.
ConnectiCare: Call 800-390-3522 Monday, Thursday, and Friday from 8 a.m. to 4 p.m. or Tuesday and Wednesday from 8 a.m. to 7:30 p.m.

Changing Ourselves First

In adopting a population health approach, the first thing we are changing is ourselves as medical directors. We are redesigning our role from a traditional, reactive, utilization management-focus to a proactive, multifaceted leadership-focus. We are acquiring new skill sets and have staffed our team with diverse personality traits, cultures, and backgrounds. This diversity gives us better insights into those we serve and makes us better partners for you.

Transitions of Care

We transitioned the management of our post-acute care programs from outside relationships to our own teams. This will allow us to build our clinical partnerships with you, optimizing the transition of care experience when a member is discharged home from a hospital, skilled nursing facility, or other inpatient site. We appreciate our hospital partners who offer our members virtual visits post-discharge to reduce readmissions.

Primary Care

Primary care plays a crucial role in a strong population health model. We have observed that patient-centered medical homes are an effective way of delivering proactive primary care. As medical directors, we want to see all of our members working with a primary clinician, regardless of whether or not there is an official primary care provider (PCP) designation through one of our benefit plan designs. Screenings, immunizations, and other preventive care can help our members achieve the healthy futures we envision for them. A strong primary care relationship, built over time and based on trust, can uncover other ways a patient needs help beyond the office visit and beyond the medical needs.

Removing Primary Care Barriers

We understand the importance of removing barriers to primary care. That is why:

Many of our plans have no or low member cost-sharing for primary care services.
We offer financial incentives, such as:
- The Adult Comprehensive Health Assessment Provider Incentive Program to compensate providers who are not part of a value-based arrangement but help close gaps in care for our members with Medicare, Medicaid, and Essential plans.
- The EmblemHealth Medicare Member Rewards Program to encourage members to seek preventive care with their clinician.

Use of Technology

There are many ways technology can help improve population health. One way is the use of artificial intelligence (AI) in identifying targeted populations with special health needs. We can analyze data gathered from claims (hospital stays, pharmacy, and diagnosis) and utilization review requests from our own systems and those of our partners to identify patients with high comorbidities, predicting who can benefit from one of our Care/Case Management programs. We also use this data to inform when new programs are needed. Our data also helps us uncover opportunities to improve transitions of care across our full range of services.

Defined

One of our key goals is to help create healthier futures for our members. To help us meet this goal and influence better health outcomes, we are adopting a population health approach.

“Population health” is a term most clinicians are aware of but may think of in different ways. At EmblemHealth and ConnectiCare, we are aligned with the CDC’s approach:

CDC views population health as an interdisciplinary, customizable approach that allows health departments to connect practice to policy for change to happen locally. This approach utilizes non-traditional partnerships among different sectors of the community – public health, industry, academia, health care, local government entities, etc. – to achieve positive health outcomes. Population health “brings significant health concerns into focus and addresses ways that resources can be allocated to overcome the problems that drive poor health conditions in the population.”

As doctors working as medical directors for EmblemHealth and ConnectiCare, we are uniquely situated to influence population health. Having you as our partners – supported by data and technology – gives us a broader perspective than what we would see from just treating patients in our own medical practices.

Making population health changes requires a multi-pronged approach. Keep reading to see all of the ways we are working to make a difference for our members.