Highlights from CipherHealth’s Inaugural Population Health Leaders Roundtable

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CipherHealth recently co-hosted the inaugural Population Health (“PopHealth”) Leaders Roundtable in New York City with Eliza Ng, MD, MPH, Senior Medical Director of Montefiore Health System’s Care Management Organization. Population health leaders from a variety of health systems across the Northeast attended the PopHealth Roundtable, including DSRIP Performing Provider Systems (PPS), Care Management Organizations, Accountable Care Organizations, Urgent Care, and Managed Care Organizations.

The diversity of organizations committed to improving the health of their patient populations is a promising indicator of the greater healthcare industry’s shift towards value-based care models. The PopHealth Leaders Roundtable attendees explored key population health management challenges that health systems are facing in today’s regulatory environment, such as integrating community-based care management within population healthcare networks and utilizing innovative technology to address the complex needs of vulnerable patient populations.

Addressing the Social Determinants of Health

According to the Centers for Disease Control and Prevention (CDC), the social determinants of health are defined as “…conditions in the places where people live, learn, work, and play, which affect a wide range of health risks and outcomes.” To improve population health and achieve true health equity among vulnerable patient populations, providers need to develop broader approaches that extend beyond traditional healthcare interventions in order to address these social, economic, and environmental factors.

Current models of care management are often facility-based rather than integrated directly into the community. Attendees identified that it is challenging to adequately capture and understand patients’ social circumstances, as the lack of continuity between community-based and clinical resources creates information silos. Managing patients’ social determinants of health in tandem with their clinical needs is critical to closing care gaps and improving care transitions throughout the continuum of care. As attendees discussed, to provide truly patient-centered care, the healthcare system needs to shift from reactive care towards understanding what the patient prioritizes – which is often related to their social determinants of health. This is proving to be critical as providers are finding that important care protocols, such as medication compliance, improve when providers inquire about and tailor care plans to the patient’s social situations.

The Evolving Role of Technology in Population Health Management

While there are many challenges in developing and deploying successful population health management programs, attendees focused on how technology may be leveraged to facilitate this paradigm shift to truly meet patients where they are. Integration with electronic medical records may not necessarily be the end goal, as the volume of data generated by patient encounters overshadows care management priorities and frequently leads to alert fatigue.

PopHealth Roundtable attendees identified the need for technology to streamline the entire spectrum of population health management, such as patient identification, stratification, prioritization, intervention, engagement, and evaluation, as well as integration with other members of the healthcare team across the care continuum. As population health initiatives become an increasingly high clinical and financial priority, moving the current state of population health forward depends on the close collaboration of providers and technology partners.

CipherHealth is committed to partnering with organizations across the healthcare continuum to serve at-risk and vulnerable populations. To learn more about how your healthcare system can gain greater visibility into the complex care needs of underserved patient populations in order to drive enhanced patient outcomes across the care continuum, see our population health management solution in action.


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