Leveraging Reporting for Population Health Approaches

A patient visits the emergency department for pain in her legs. She's seen by a doctor, given a prescription and a follow-up appointment is booked. The patient, who is also homeless, leaves the hospital and loses that slip of paper. She doesn’t have a cell phone number to be contacted at. She misses the follow-up.  
The next time the patient comes in, the same protocol is followed – there is no change in the outcome.  

This is just one example of moments in healthcare when taking a population health approach could make a world of difference.  

When population health is brought up in healthcare circles, the conversation is often unwieldy. There are many different definitions and applications of the concept. According to the American Hospital Association, population health is defined as “the health outcomes of a defined group of people.” There are many ways to define a population: geographic area, community or experience, to name a few.  

As many healthcare organizations know, implementing a population health based approach can be challenging. Some reported obstacles include identifying populations, creating care plans and connecting with patients and communities. Taking a population health based approach necessarily involves taking a different perspective on communities, patients and care.  

How reporting can help  

When it comes to population health, reporting can fill significant knowledge gaps. For example, there are any number of reasons for why patients who are also homeless don’t make it to their follow-up appointments. They could:

  • Have a fear or history of negative experiences with healthcare. 
  • Have a hard time keeping track of appointments.  
  • Be struggling to manage other conditions, like mental illness or addictions.  According to the American Psychological Association, mental illness is twice as common among people who are homeless.  
  • Not have the money or means to make it to the appointment, depending on its location. 
  • The appointment could have conflicted with meal time at shelters, which might be their primary resource for food.  

In this case, it is more than a missed appointment, it is a product of lived circumstances. But without a record of that information, it just looks like the patient can’t keep appointments, which is often identified as non-compliance. In these cases, reporting provides an opportunity to gather robust information that can inform approaches to care and, hopefully, yield better outcomes. It also allows healthcare organizations to track and identify characteristics of populations they interact with that could benefit from a different approach, from under-housed populations to new immigrants.  

Taking this approach doesn’t just improve patient outcomes, it also can improve metrics like readmissions. A study in the Joint Commission Journal on Quality and Patient Safety linked Medicaid readmissions to social determinants of health, including financial stress, mental health disorders, substance abuse and lack of housing. Using reporting to build knowledge about these factors, and how they affect your patient population, can contribute to better results for your patients and your organization.

If you're joining us at RL Palooza, check out the session "Is it Non-Compliance or is it a Social Determinant?" Or learn more about RL6's powerful reporting capabilities.  


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