Where Population Health Gets Really Real: Caring for Communities in Need

Sept. 23, 2019
Three Los Angeles healthcare leaders share their perspectives on population health management in the context of caring for communities in need, at the California Healthcare Innovation Summit

It was wonderful to sit down with three Southern California healthcare leaders last Thursday, September 19, during our California Healthcare Innovation Summit, held last Thursday and Friday at the Sofitel Hotel Los Angeles at Beverly Hills, to discuss a subject of supreme importance—applying population health management strategies to the care management of communities in need. The headline of our panel discussion was “Caring for the Health of Communities Cross the Continuum of Care”; and my esteemed discussants were Ursula Baffigo, M.D, M.P.H., IPA medical director and regional medical director for AltaMed Health Services, the largest system of FQHCs (federally qualified health centers) in the Los Angeles metro area; Anshu Abhat, M.D., M.P.H., director of care transitions and patient engagement, population health, in the Department of Health Services, Los Angeles County; and Matthew Pirritano, Ph.D., M.P.H., director of population health informatics at L.A. Care Health Plan, the contracted MediCal (Medicaid) health plan for Los Angeles County. All three leaders are in organizations caring for impoverished and needy patients and plan members in some of the state’s neediest communities. And all are deeply involved in finding new ways to innovate around population health and care management in those communities.

As the panel description in the Summit’s agenda noted, “More and more, population health management is coming to encompass broad approaches to caring for the health of entire communities, including of communities in need. The social determinants of health, poverty, and housing and food insecurity, are elements involved in this mix, as are the need for patient care organization leaders to be able to develop high-level data and analytics that they can leverage in order to approach health as broadly and strategically as possible. This panel will provide insights from the FQHC (federally qualified health center), integrated health system, and health plan perspectives, on this important subject.”

Among other things, I asked the three leaders how they and their colleagues are rethinking population health management in the context of communities in need. “We have traditionally outlined population health based on a medical condition, but that’s evolving into new work around the social determinants of health,” Dr. Baffigo said. “We were seeing patients with tremendous hospital lengths of stay. For example, a patient who only needed a 10-day stay was staying in the hospital two, three, four months at a time. Care teams were working hard to move them, but they have other issues, sometimes including substance abuse, so the only recourse is to keep them in the hospital. Those are very expensive patients.” Discovering through analysis how many patients were in such situations “triggered new emphasis on preventing patients from going to the ER, and these patients often do not often go to their primary care physicians, as they have many challenges. We have a case management team, and we do contact with L.A. Care, and are trying to figure out how to reach those patients” and manage their care more effectively. “That’s how we have evolved into looking more into the social determinants of health.”

The landscape around this is “changing quite a bit,” Dr. Abhat noted. “Instead of stopping at, ‘This patient was admitted into heart failure,’ and that’s it, we’re starting to ask deeper questions: do they have food insecurity? The food in homeless shelters is not healthy. How about housing or transportation insecurity? We’re just starting to look at those social determinants. You leave the hospital and don’t have transportation to get to your next appointment; that seems like a simple problem to address, but it’s actually complex. As a patient, you have to ask for [transportation support], and be plugged in on both hospital and clinic side. Does a social worker do it [arrange for transportation], or someone else? But we are understanding that not everyone has to be licensed to ask about transportation. In many cases, what we’re finding is that we have to get out of the ‘medical brain,’ and into the ‘real world brain,’ in to solve these issues.”

And L.A. Care’s Matthew Pirritano noted that “The social determinants of health that we’re discussing here are a big part of the population health landscape. It’s important to realize,” he emphasized, “that at least 50 percent of the health outcomes are attributable to something outside of a person’s control or clinical control. Looking at the data, we know that for one, most of the homeless folks in L.A. County are our members. So how do we get care for those people, get them to see a doc regularly? If they have diabetes, where do they keep insulin if they don’t have a refrigerator? We’re aware of these issues. We did a procurement recently for a new transportation vendor, for example.”

What’s more, Pirritano noted, “Most Medicaid members don’t regularly see their doctors. They might have had an ED visit, but their primary care physician might not even know about it. So bringing those people in to address these concerns is key.”

“For an IPA [independent practice association], there often isn’t that personal connection,” Dr. Baffigo noted. “We try to have that happen through case management. Sometimes we have our IPA care team, a team of professionals, nurses and case managers, have those meetings in Spanish as much of our population speaks Spanish. We have bilingual staff.”

Importantly, Dr. Abhat noted, “Having good and actionable data at different points the continuum. We are almost a contained network and we’re the providers. But I would love to have a stratified risk [determination] for a patient who is discharged, matched against our population. When you are not able to use data actionably in that moment, it’s difficult to create pathways. “We’ve got a long way to go. There don’t yet exist great Medicaid models out there around risk stratification. Health plans are doing better, but for health systems, not as much yet.”

And, noted Dr. Baffigo, “We were having a great challenge identifying the homeless populations. We determined that the data was very poor when trying to figure this out. It was found through inpatient admissions, or through case managers. Two different modules that don’t talk to each other, so we cannot create a report that pulls all our homeless patients who aren’t duplicate.”

As for addressing the social determinants of health more broadly, Pirritano referenced the September 4 announcement on the part of his organization, L.A. Care, and Blue Shield of California Promise Health Plan, that the two health plans will be investing $146 million to fund the expansion of a constellation of community resource centers across Los Angeles County. The two health plans, as their CEOs noted in interviews published in an article published on September 11, are committed to care for the social, as well as medical, needs of their plans’ members.

With regard to such efforts, Dr. Abhat noted that “I’m seeing healthcare absorb a lot of other social issues, and maybe that’s not always a good thing; but we’re seeing a lot of it moving forward.” Inevitably, she said, even though the healthcare system might not be the ideal venue in which core housing needs are addressed, because some of those issues have fallen to healthcare leaders and organizations, and inevitably, healthcare leaders need to act, given the facts on the ground. As she put it, “A lot of housing is starting to have an interaction with healthcare. Lot of safety net services are starting to have a deep connection with healthcare. So I’m not sure healthcare spending is going to go down any time soon, because we are doing that linking. But I am hopeful we can better leverage analytics and technology to gain efficiency, such as connecting clinical pharmacists with patients in telehealth format.

Meanwhile, working with data remains an enormous challenge. “There are so many challenges in terms of getting the right data to make it actionable,” Dr. Baffigo noted. “For homeless patients, I’d love to have the data entry be as valid as possible. It’s so difficult right now to bring in the different data points from the different depts that touch that patient. We’re still largely dealing with software systems that don’t talk to each other.”

The issues that the three healthcare leaders—Baffigo, Abhat, and Pirritano—discussed with me on Thursday in Los Angeles—go to the heart of the challenges facing the U.S. healthcare system, as the leaders of hospitals, medical groups, and health plans figure out how to strategize forward to meet the needs of their patients and plan members. And inevitably, doing so now means thinking about the broader dimensions of health status—including the social and socioeconomic dimensions of health status—for broad populations of individuals and communities in need.

And if organizations like L.A. Care, AltaMed, and the Los Angeles County Department of Health, can make progress tackling these issues, then there really is hope for the overall U.S. healthcare system. And that’s saying something.

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