Sunday, December 17, 2017
Deborah Keller, RN, BSN, CMCN
TCS Healthcare Technologies

Targeting High-Risk Patients through Population Health

There have always been substantial gaps in healthcare services for the higher-risk populations. Despite the best intentions of structure managed care programs introduced as early as the 1970’s, these gaps persist.

This isn’t breaking news—over the past two decades, the term “vulnerable populations” has gained prominence in the healthcare industry. Messaging in the late 1990s to early 2000s was consistent: Certain populations are at greater risk because of who they are and where they live, regardless of their actual health condition.

Of course, along with evolving healthcare trends come new buzzwords. One of the most common is Population Health Management (PHM), a concept that has made significant inroads during the emergence of integrated delivery systems such as accountable care organizations, patient-centered medical homes and hospital-based readmission prevention programs.

As a result, the practice of case management is evolving to accommodate some of these new opportunities. The emerging PHM approach overlaps significantly with existing care management programs, but also includes additional tactics to improve the clinical and financial outcomes of the targeted populations. As more complex care management interventions and evolving PHM strategies are deployed and integrated, case managers directly engaged in population health activities with patients need to understand the changing landscape.

The PHM Model

PHM aims to improve health outcomes by providing better access to care, improving the quality of care, and increasing preventive care. In doing so, PHM has the potential to improve the entire health care system while reducing costs.

PHM is defined as, “The health outcomes of a group of individuals, including the distribution of such outcomes within the group.” (Kindig D, 2003) The PHM model involves coordinated care efforts that go beyond managing specific “cases” or “situations.” It also includes improving the health outcomes of populations by providing a spectrum of services directed at behavioral change and healthy lifestyles to obtain optimal outcomes.

The model is based on utilizing a team of caregivers, including case managers, attending physicians, other providers and family members. Populations and individual patients are targeted across a wide range of medical conditions and social and physical environments. The flexibility and comprehensive nature of the PHM approach is one of its hallmarks.

Population health management is now more important than ever due to shifting reimbursement strategies, such as performance-based compensation. For example, hospital revenues are moving from inpatient care to outpatient, and physician reimbursements are transitioning from individuals to entire patient populations, and from volume to value. For a PHM program to be successful, stakeholders must leverage advances in technology such as varied forms of communication, provide culturally competent support services, and identify relevant metrics for a continuous evolution that fits the needs of the population being served.

Healthcare Technology Advances

In recent years, healthcare technology has grown in its ability to easily identify vulnerable populations. This capability has resulted in improved development and performance of interventions to manage health risk associated with access barriers. Advances in healthcare technology have been an integral part of making the management of these at-risk populations possible.

For example, through the use of simple algorithms, care management solutions can flag patients as “at-risk” due to geography, and ensure the member is connected to a provider to receive appropriate intervention.

Technology also supports more robust communication with vulnerable individuals. With options for the use of social media, text messaging, email, video conferencing and other alternatives to the classic phone call, significant opportunities exist for patients to fully engage in their own care.

Two of the most dramatic examples of using technology to reach patients with poor accessibility to care are the implementation of telemedicine and telehealth. These terms are often considered interchangeable, but they are not—telemedicine is the remote delivery of healthcare services via technology, while telehealth is a broader term for using technology to advance medicine, such as advanced practitioner training, continuing medical education and delivery of non-healthcare services.

Leveraging remote monitoring, smart phones and wireless communications also can help optimize PHM strategies and outcomes. With the growing reliance on electronic health records, telemedicine platforms and technology applications to promote affordable, high-quality, person-centered healthcare, a better understanding of the new mobile environment is now a necessity.

PHM information technology programs rely heavily on informatics and data analytics to identify and measure the effectiveness of population-based interventions and help promote an interconnected healthcare system. Being able to aggregate and summarize patient health histories, along with the creation of detailed care plans, is essential to managing the ongoing care of the targeted individuals within a group.

Care managers must have access to IT systems that can support the PHM model, including implementing risk-assessments that help create customized care treatment plans, promoting automated workflows and documentation, stratifying opportunities to identify and manage targeted populations, and tracking/reporting financial and clinical outcomes – among other capabilities. It also will be nearly impossible to provide the reporting these programs require without the use of IT systems.

Enhanced Communication

Dozens of factors go into the design and implementation of a successful PHM program. Of course, face-to-face meetings and telephonic interactions will remain indispensable, but leveraging emerging communication assets are also important. Easy tools are necessary to encourage patient education, engagement and self-management. 

For instance, millions of patients use the Internet to review test results, schedule appointments, get health information, and email their physicians. The rise in social media interactions to support patient health is another rapidly expanding communication trend. Similarly, text messaging, email, online video chat, VOIP-based telephone systems, and other communication channels will increase our ability to stay connected with family, caregivers, providers and others.

Leveraging remote monitoring, smart phones, and wireless communications also can help optimize PHM strategies and outcomes. With the growing reliance on electronic health records, telemedicine platforms, and technology applications to promote affordable, high-quality person-centered healthcare, truly understanding the new mobile environment is now a necessity.

Changing Mindsets

The Patient Protection and Affordable Care Act has the potential to improve access to healthcare, and while the approaches to increase the number of insured Americans varies, most people believe everyone should have access to healthcare. The enactment of the Affordable Care Act has exposed many people to previously unknown healthcare issues.

The Office of Minority Health and Health Equity defines vulnerable populations as groups that fall either outside society norms or do not engender much awareness by society. For example, the push for wider understanding and acceptance of individuals within the lesbian, gay, bisexual, transgender and questioning (LGBTQ) society has helped diminish barriers to appropriate healthcare. Health risk assessments and health surveys now ask specific questions to align healthcare to the gender and sex of the patient.

Efforts to address the needs of other populations, with historically limited access to healthcare, has ensued. For example, the push to educate our broader society about HIV/AIDS has reduced the stigma of the disease that for many years forced patients to seek treatment far from their homes, or not at all.

Unfortunately, while significant gains have been made to remove the stigma of behavioral health disorders, many barriers remain including social barriers to patients seeking and receiving behavioral healthcare. Certain serious mental illnesses such as schizophrenia are often identified as a vulnerable population for this reason.


Although vulnerable populations have always existed, the disparities in the healthcare they receive have been under the radar. The previous division of people without health insurance—low-income families, and racial and ethnic minorities and the rest of society—is beginning to shrink as healthcare experiences a paradigm shift to a focus on population health management. The needs of these vulnerable groups are now being addressed. If society strives to identify the people most at risk and invests in building the tools and talent to take care of them—and more importantly for them to take care of themselves—the definition of “society” is retained.

In healthcare, this means continuing to develop technology that helps address barriers to healthcare access, enhancing communication outlets and remaining educated about vulnerable populations.

Kindig D, Stoddart G. What is population health? American Journal of Public Health.2003; 93:380–383. [PMC free article] [PubMed]