More Than Checking Boxes: The True Meaning of "Solve"

Now we get to where the rubber meets the road.  The Solve step of the Population Health Sycle.  We have Selected our population, Surveyed and Segmented them, and they’ve been enrolled in the Sell Stage. Now they’re in. 

So what are we going to do to Solve the myriad of things we have identified to improve their health?

First, what are the key features of your program?  Is it telephonic? A community-based face-to-face model? Using tech such as RPM or messaging? Is it run out of clinics in a distributed model, or centralized through a contact center, or some combination of each of these? All of this needs to be clearly defined to connect with, assist, and retain the individual and clinicians while working to improve outcomes.

Furthermore, within your model, what does your staff look like? Nurses, dieticians, social workers, counselors, Community Health Workers (CHW’s), aides, outreach staff, and on and on. The composition and ratio are critical and depends upon the population you selected and the impact you hope to make. One of the biggest mistakes I see is under-staffing the program.  As I’ve said many times before, you cannot lift a 5 lb brick vertically with only 4 pounds of force.

Personally, I am a big fan of some form of a face-to-face model, where staff visit individuals in their homes.  While this is more expensive, the relationships are stronger, the issues identified are better understood, particularly the person’s home and community situation, and combining this with tech can be a powerful and relatively efficient approach.  Using CHWs in this model is the key, especially when working in disadvantaged communities.

So what’s next? I hate to use the term “Closing Gaps in Care “ because most programs focus exclusively on this and think that’s what a population health program is all about. 

“I just have to check the boxes, and we’re good to go.”

But it’s so much more than that.

Yes, we need to be sure the patients:

• are scheduled to, and attend appointments and fill their prescriptions,

• have USPSTF screening, and other services as per the guidelines. Thereby checking the boxes.

But it’s also about

• Behavior change

• Education

• Clinicians following guidelines as appropriate and ordering effective and appropriate medications

• Integrating the services across the continuum and ensuring all the clinicians have the information they need regarding the patient.  A simple example:

When running an HIV/AIDS program, there was a patient whose viral load spiked.  The nurse discussed it with the physician, who said it was probably a blip. The nurse then met with the patient, who, after some prodding, admitted they were not taking a medication due to some side effects.  They asked if the patient would tell the physician at their next visit, to which they responded hesitantly. The nurse attended the visit and had notified the physician in advance of the adherence issue.  When the physician asked if they were taking their meds, the patients said “yes”, then looked at the nurse and said “no”.  The physician changed the medication to something more tolerable, and the patient did better.

Key points:

• The nurse had a relationship with both the patient, who felt comfortable disclosing the issue.

• The nurse had a relationship with the doctor and gave them a heads-up about the issue.

• They had access to both claims and clinical data to know the patient had been filling the prescription, but their viral load had increased.

• The nurse attended the appointment due to the patient’s hesitancy to disclose their concerns. 

• Solving for the Social Determinants of Health.  This can create large improvements in outcomes. Ensuring housing, food, transportation, etc., makes a meaningful difference in quality of life and clinical outcomes.

It’s also important to identify community resources. Healthcare systems have their expertise, but much of the work required can fall outside their realm. Partnering with good resources is critical.  Also consider that just as we look to value for our clinical services, we need to consider value in our partnership services as well.  These organizations also need to be accountable for their outcomes.  Esther Dyson commented after launching the Way to Wellville that she would no longer work with organizations that just measured process. Hear, hear!  We all need to measure outcomes, including the community groups and other not-for-profits, to demonstrate value.

This is but a quick and limited overview of all that can be done in the Solve Step.  If you’d like to discuss your program, reach out to us here.