Population health is shaping the future of healthcare

Medical care alone is not the answer

Our country’s healthcare system spends a lot of time and resources treating the symptoms and causes of injury and disease, though data has shown that medical care addresses fewer than half of the factors impacting health outcomes.

So, what are the other factors? Typically, they are social determinants of health, which can include social, economic, and environmental factors as well as health-related behaviors.

This data point may seem shocking, but it plays out in real-time across the senior care sector every day. A person experiences an event that impacts their health — a heart attack or a fall. They visit a doctor or hospital for treatment. In most cases, they get good care and advice, but rather than recover, their health stagnates or declines. They can end up in a cycle of ER visits, hospital stays and readmissions — a bad result for both the individual and our healthcare system.

Driving this unfortunate cycle are numerous challenges that the person’s healthcare provider might not know exist. The phrase “social determinants of health” often conjures images of poverty, addiction, or abuse. For the people we serve at Spring Hills, these are certainly possibilities, but more often they face subtly detrimental life conditions. The individual might live alone — with little family support. They might lack transportation to get to the pharmacy or follow-up appointments. They might not fully understand a care plan or have the right support to implement it. They might not be able to shop for or prepare food for a special diet. In many cases, several factors may be present.

My team is all too familiar with these dynamics, after seeing countless seniors fall through the cracks of the healthcare system through the years. We can — and must — do better. Building on our experience providing high quality senior care, we have set out to solve this prevalent problem through population health management. This emerging field helps operationalize the idea that an ounce of prevention is worth a pound of cure. It pursues positive health outcomes by considering all factors impacting a person’s health or ability to stay healthy. It actively engages patients in their treatment plans and helps them to overcome barriers to success.

Providing seniors and their families with options so they can make informed decisions about their healthcare.

Spring Hills Population Health is focused on ensuring better outcomes; engaging patients, families, and caregivers; and addressing challenges to our patients’ achieving improved health. Population Health associates are integral members of our care teams, providing insight to the clinicians creating the treatment plans and guiding patients and families as they learn new behaviors and access the support they need to do so. This begins when the patient is in the hospital, to ensure a smooth transition to Spring Hills, and continues during their stay and for 90 days post-discharge. Services include coordination of care, personalized communications, home visits, remote monitoring, and addressing social and financial barriers to accessing care. Our Cardiac Program, which launched last month, demonstrates how this model can be customized for people with specific health conditions.

Having been in senior care for a long time, I know how important it is to regard and respect every senior as an individual. I also know that living environments and supportive care matter greatly to health outcomes. By providing seniors with options, rather than top-down directives, we equip them and their loved ones to make more informed decisions. Through our population health program, Spring Hills helps people achieve greater health, making our healthcare system more effective and less costly for all involved.

Population health management is an innovative answer to a common challenge — and a win-win for all parties involved. Doing the right thing often is.