Imagine a utopia where everyone suddenly got healthier. They exercised regularly and ate what they should. And they seldom needed to spend time and money to see a doctor for illnesses or to take multiple medications.
That sounds idyllic – but then what happens to hospitals and clinics? That's where something revolutionary can happen. With fewer sick patients, health systems can begin moving from treating illness to supporting wellness. And the payments would follow: Money currently invested inÂ interventions could be targeted toward prevention.
An increasing number of health systems, including Sanford Health, have started taking steps toward a climate that resembles this utopia.
Population health is difficult to grasp in a sentence or two. Even across health care systems, the movement can take on different meanings.
Sanford Health defines it as the transition to value: taking meaningful, strategic steps to help patients and the system move from taking care of people once they're sick to helping them practice healthy lifestyles today. Then they can lower their risk of preventable conditions or incidents that could otherwise send them to the emergency room, or into surgery, or to their doctor for medications.
Patients save time, money and heartache, with prevention typically costing far less than the cure. And hospitals and medical staffs can concentrate more resources on patients with serious medical needs. The healthiest patients may need just a doctor visit a year and their recommended screenings.
"I like to think about population health as total health," said Emily Griese, director of population health for Sanford Health. "So that includes, 'We can absolutely fix patients when they're broken,' but we can also understand and support all of the upfront work that can help that fix from ever being needed."
This is not an easy transition; it involves many factors. Technology, for example, plays a role in collecting data about people – their age, gender, health history and risks, for starters – and analyzing it. The business side explores shifting payment models by health plans and the government.
And the human side tries to identify barriers faced by patients in everyday life, including making sustainable and meaningful changes to begin living a healthy lifestyle. It looks at how those differ for different populations: those living in rural communities; those with busy young families; or those who struggle to afford healthy foods.
Population health doesn't just look at groups of people, though. It also allows health care teams to get personal. To pinpoint individuals using the health care system who might need a helping hand of a different sort – and then help guide them to that helping hand.
"I think as we get increasingly better at recognizing all of the complexities around individuals' health, that it's not just their access to health care, it's also their environment they live in, it's their genetics, it's their behaviors, it's all of these pieces around them, and we have to get better at understanding that full puzzle," Griese said.
Health care systems have tools and technology that can help. They can screen patients for social factors that affect how they live their lives. The screening can find out whether a patient has concerns about housing, access to healthy food, or issues with transportation.
Health care systems can also analyze data that flags, for example, which patients move often. It can show which patients visit the emergency room regularly when they don't actually have an emergency. Maybe they lack warm or safe housing, or they're lonely and want to connect with someone.
Sanford Health has staff who can reach out to determine patients' challenges and help address them. To do this work right, and most effectively, it takes a team. While Sanford Health provides high-quality health care, there is an opportunity to team up with community organizations to really make the difference.
"We recognize that we can't do it all alone, and we're going to have to rely on our community partners to help us take care of these individuals," Griese said. For example, Sanford Health has partnered with Lyft to help get people to and from their appointments.
And Griese's experience with a Volunteers of America, Dakotas research project led to a partnership between Sanford Health and the VOA, Dakotas. If a Sanford Health patient can use some kind of help with an issue outside the scope of the health care system, such as housing or substance abuse, the VOA can help address it. If the VOA sees a person in their areas of service struggling with a health concern, they can turn to Sanford Health.
Community involvement aimed toward prevention, along with advances in telemedicine, can help lift harder-to-reach populations as well.
"Now we're helping them have the environment around them to really be healthy," Griese said.