Physicians know there is no easy cure for a patient's inability to purchase needed medications or drive to the nearest pharmacy.
Arthur Kaufman, M.D., vice chancellor for community health at the University of New Mexico Health Sciences Center, discusses innovations in population health during a forum hosted by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.
Too often, the socioeconomic factors in a patient's life don't receive the attention they merit, and that is where the value of population health becomes clear. Many physician practices are beginning to address some often-neglected health factors, such as living conditions inside the home or a patient's employment status. Physicians typically don't ask about these topics during an office visit, but they can greatly influence a patient's health outcome.
Some institutions are tackling these social factors by evaluating the entirety of each patient's needs and then assigning a health professional to ensure that any barriers to care are removed. On June 18, the Robert Graham Center for Policy Studies in Family Medicine and Primary Care hosted a forum(www.graham-center.org) during which panelists discussed population health and, more specifically, how patients' health and socioeconomic needs can be accommodated.
Addressing Social Determinants of Health in New Mexico
In New Mexico, Native Americans rank highest in diabetes screening and receipt of preventive services compared with other groups, yet their mortality rates from the disease are also the state's highest. Arthur Kaufman, M.D., vice chancellor for community health at the University of New Mexico Health Sciences Center in Albuquerque, said population health statistics for targeted groups indicate that access to care is not necessarily a major reason why a certain community reports poor health outcomes.
- Many physician practices are beginning to address some often-neglected health factors, such as living conditions inside the home or a patient's employment status.
- Borrowing the concept from statewide agricultural extension offices that exist to help farmers improve crop production, New Mexico created health extension offices to address local health concerns.
- Changes in the way physicians and patients interact are occurring rapidly, but changes in the respective demographic characteristics of the two groups are not.
Kaufman, who previously worked for the U.S. Indian Health Service, said Native Americans have the highest prevalence of adverse social determinants, including low education, poor nutrition, high unemployment and social marginalization. Most people might not associate such factors with health outcomes, but morbidity and mortality data support such a link.
"This burdens primary care practices," Kaufman told forum attendees.
Practices in the New Mexico university system are aware of this data because their patients are asked to complete a social determinants questionnaire that asks about personal needs such as housing, food assistance, substance abuse, transportation or domestic violence. Such issues may be difficult for a physician to address directly, according to Kaufman, so the questionnaire results can be invaluable in painting a complete picture of a patient's life.
"Without this, I would never ask a patient if he could pay his utility bill," he said. "We have the population data right in front of us."
If one or more social issues poses a barrier to care, the physician can refer the patient to a community health worker who then, for example, helps the patient obtain financial assistance to pay a utility bill or get a ride to the physician office.
"Community health workers are unknown in the medical system because they don't train in academic centers, but they know far more about the community," Kaufman said. "They address the social determinants of health."
The workers typically reside in the communities in which they work and are fluent in the local language. They have various educational backgrounds and are charged with not only carrying out a physician's orders but assisting patients with other needs that influence health outcomes. New Mexico is home to 600 such workers.
Borrowing the concept from statewide agricultural extension offices that exist to help farmers improve crop production, New Mexico created health extension offices(www.annfammed.org) to address local health concerns and identify social determinants of disease. Ten states have or are developing a community health worker program, and 16 states are doing the same with health extension offices, a sign that the nation still has a long way to go to adequately address population health.
"If we keep doing this piecemeal, we're not going to get there," said David Meyers, M.D., acting director for the Agency for Healthcare Research and Quality's Center for Evidence and Practice Improvement. "If we only fix the health care system in isolation, we're not going to get there."
Changes in the way physicians and patients interact are occurring rapidly, but changes in the respective demographic characteristics of the two groups are not. One looming question about population health is the demographics of the current physician population. A physician who is a member of an ethnic minority group is five times more likely to see a minority patient than a physician who is white. It's particularly important that in areas with large minority populations, such as New Mexico, this trend be addressed.
"We can't afford to wait 50 years for the physician population to look like our patient population," Kaufman said.
Blending Big Data With Small in North Carolina
"Big data" -- that is, wholesale data collected from hospital visits and insurance claims -- and its role in population health is a topic of great interest in health care circles these days. One state health network, however, is touting the value of "small data" to reduce hospital admissions.
Community Care of North Carolina (CCNC) comprises 14 regional networks of medical homes that include some 6,000 primary care physicians -- about 90 percent of medical practices in the state. All told, CCNC saved Medicaid nearly $1 billion(www.communitycarenc.com) between 2007 and 2010 by, among other things, using a coordinated care approach to reduced hospital admission and readmission rates by 10 percent.
Recently, CCNC partnered with pharmaceutical manufacturer GlaxoSmithKline to develop a database that assigns a risk score to patients. Called Care TRIAGE,(www.communitycarenc.org) the program predicts whether a patient is at risk for hospitalization or a problem with drug therapy using specific clinical information along with data about patients' medication adherence gleaned from community pharmacies.
"Pharmaceutical data is the only thing in health care where we get real-time data, but we don't get it back in the hands of physicians," said CNC president and CEO L. Allen Dobson Jr., M.D.
He said a patient who is on three different medications may not be taking them because they are too expensive or because they cause stomach pain, but no one providing care for the patient may be aware of the issue. The primary care physician, urgent care center and local pharmacy need to have an integrated data network that keeps vital patient information "liquid."
In general, said Dobson, coordination of patient records among primary care physicians, subspecialists and other members of the care team is the "biggest disconnect in this country." Rather than forward an 86-page continuity of care document, physicians and other health professionals need to include "actionable data" that explains why a patient needs continued care and why previous efforts have failed.
"We can't change the disease, but we can change the program of care over time," Dobson said.
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