How do you manage population health at a community level with an organization as large as Providence, where you have facilities spread out across several different markets?
We are both large and small. We truly believe that healthcare is delivered at the local level with the individual patient, their caregivers and healthcare providers. At the same time, we leverage our size. We span seven states. And that means that when we are going out and finding the expertise, the tools, the procurement, the investments—we can leverage our size to do a better job of using the resources that we acquire. But when we deliver the actual care, it’s at the local level.
What technology do you use to identify the areas of need within each community?
We have a great number of people who have helped us create a proprietary platform we use. You use the electronic health record, but you also use claims data to get an idea about how frequently they access care. You can also use that to supplement information about utilization of care.
We supplement that with social determinants of health information, both publicly and privately available. And then we actually ask people how they perceive their health outcomes, how they perceive their access to care and what we could do better.
It’s a combination of a lot of resources coming together, and we put it into a common platform, so that all of our team members can access it at an appropriate level. That platform is called Community Pathways to Health. It has been helping us get through not only COVID-19, but every area of work that we have to do as we try to resolve health disparities.
How do you put those insights to work?
First, we got everybody educated on what is actually happening in their communities. That was really important, because not everybody understood what health disparities were, which populations were impacted and how they were impacted. We took that information and built out a five-year strategic plan.
We focused on COVID-19 and a whole host of very clearly defined health disparities impacting various populations. From Alaska to Texas, we are taking care of people from all nationalities, ethnicities, races, languages, gender identities, levels of disability and levels of mental health.
We took that information and used data-informed interventions to measurably improve. Some of those improvements involve the social determinant factors in the community, like homelessness, access to food, access to transportation for medical care, or access to telehealth-type services. Some are directed toward the actual care for a specific condition, such as colon cancer screening and treatment, breast cancer screening and treatment, diabetes, hypertension, heart disease, mental health and substance use disorders.
When we build out these interventions at a local community level, we also make sure we embrace that old adage: “It doesn’t count unless you measure it.” So the data informs, but the data also tells us about our progress and whether we are being effective. There has to be a measurable improvement, and part of that measurable improvement is not only the clinical and medical indicators, but also how people are perceiving their own health. And that means actually having consumer input on their experience.