Sheena Thakkar | April 3, 2018

The US healthcare system has traditionally been focused on reactive medicine, treating symptoms as they arise. When a patient has a health issue, they make an appointment with their physician, who then makes recommendations on how to improve that issue. In recent years, there has been a greater focus on treating patients with a population health approach. With this approach, patients are looked at holistically and their treatment plans are developed proactively, incorporating  a number of factors including social determinants into their holistic treatment needs.

Scenario: A patient is readmitted to the hospital for Congestive Heart Failure (CHF) complications. The physician identifies the patient has been experiencing chronic high blood pressure. The physician then monitors the patient’s vitals, and asks about his diet and exercise. The physician  suspects the patient’s diet & exercise patterns aren’t supportive of maintaining a healthy blood pressure. This patient has been consuming less nutrient dense food, and more packaged foods rich in sodium. The physician provides the patient a care plan that includes nutrition education resources and links to local access programs to create positive behavior change and a support network within the community.

Shifting the care delivery approach from reactive care to a value-based model that focuses on populations is necessary to slow the growth of our nation’s chronic disease diagnoses and related complications, like the scenario outlined above. Given the increasing prevalence of chronic disease in the US, the implementation of effective population health management is essential and timely. Proactive, and preventative medicine embraces external factors and early detection efforts such as screening at-risk populations as well as strategies for managing existing diseases, related complications, and comorbidities.
There are many scenarios similar to the one above that demonstrate the need to understand health issues at the population level. Physical health doesn’t happen in a vacuum and it’s imperative to take into account a patient’s social determinants of health. As this information is collected and considered on patients, population level insights and trends start to emerge and providers are able to derive the factors that contribute to understanding and treating patients, to meet them where they are.
But what does population health really mean? The term has been widely defined in healthcare. It was defined early on by Greg Stoddart and David Kindig as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” It has grown to include efforts like coordination between various healthcare providers that touch a patient across the continuum in order to provide necessary interventions, sooner. At Veta Health, we focus on the last mile of population health with essential patient-facing tools that bring patients into the fold of their own health management to improve long term health outcomes and encourage lasting behavior change.
As this shift is occurring, it’s essential for health professionals to focus on what population health can achieve, especially as it relates to improving rates of chronic disease prevalence and reducing the rates of associated complications. The leading cause of the death in the United States is now chronic illness, specifically – cardiovascular disease, cancer, pulmonary disease, asthma, diabetes and arthritis. Chronic conditions impact  45% of the population and their long term effects can significantly reduce a person’s quality of life – especially if left untreated. As the volume of these diagnoses continue to climb, with an expected rise to 57% of the population impacted by the year 2020, we must examine how to treat these patients, with a heightened focus on how to effectively slow the growth of deterioration in various populations.
Population-centered health will also continue to play a large role in the success of the future of value based care models. As we begin to factor in the social determinants of health and analyze key health indicators to connect patients to the right resources at the right time, we move the needle on driving higher value care, lower costs, and improved long-term outcomes.
At Veta Health, population health is at the forefront of our approach, utilizing digital solutions to improve transparency for physicians and drive effective self-management for patients. We’re focused on streamlining delivery of patient generated health data (PGHD) to providers to encourage valuable patient and physician interactions sooner through increased transparency throughout the patient care journey.
As the healthcare system continues to focus resources on effectively shifting to incorporate population-centered care models, success will depend on collaboration across all aspects of care delivery, with patients at the center. Providing care pathways that address individuals and populations, enable value-based care models and improve quality of life.