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Jennifer Houlihan, MSP, MA - Rural Population Health
Episode 201st December 2022 • Move to Value • CHESS Health Solutions
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In this episode, we continue our conversation with Jennifer Houlihan, Vice President of Value-based Care and Population Health for Atrium Health Wake Forest Baptist, about the need for value-based care in rural population health.

Jennifer what are some of the rural focused value-based strategies that you're currently employing?

That is actually been a focus for us many years. So working with CHESS evolving our Medicare Shared Savings, Medicare Advantage, scaling that now to our Medicaid population, we have been building what I would say is a foundation of value based capabilities that almost from day one we also scaled immediately in our rural communities. So some of those include working closely with our providers and to promote Annual Wellness Visits and that's such an important piece of the work that we do to close care gaps, address those social drivers of health and really proactively identify the patients that we need to care manage, So working with our rural providers to build out a process that works well for their clinics and making sure the patients, through those e-consult virtual visits and proactively scheduling them in, are able to get to their medical home in a timely manner to do that. So that that's something we've really focused on with our rural providers and that's where some of the wrap around transportation and other services come into play. Access is such a critical piece of that. Transitions of care would be another one. We have put RN resources in the ED; we work very closely with our hospitalist program, and part of that is development of the hospitalist to home program so that that allows patients to be maybe be discharged early home but putting in additional supports with our care management team; our community health worker team; social work; as well as some remote patient monitoring to help them be successful and hopefully not get readmitted. And then other supports that kind of play more of a behind the scenes role include some of our robust analytics. So doing some risk stratification work, which again, just really helps us understand the population from who has high social needs? Where is there polypharmacy? Do we have patients who have multiple chronic conditions? Allowing us to understand who's seeing their primary care provider, who needs to be scheduled in and create a more proactive approach and I do think that's very important in rural because again we might have more scarcity of resources. So really trying to be proactive and sort of leverage some of these other access ways to provide a medical home support becomes even more key. And the analytics also allows us to know our patients, know all of the care gaps that we need to address, but then also evaluate whether what we're doing is working and sort of shift that around. And so knowing where we may have provider gaps working with our family medicine internal medicine departments, making sure we can scale resources where we can from that perspective also is something we've worked on.

Jennifer is it sometimes difficult to think in entire population segments concerning outcomes? You're looking at vast groups. Do you find that to be a challenge in terms of moving the needle in public health?

In our region we have about 250,000 unique patients and it is a lot of data. We're getting data from the EMR on multiple clinical indicators with our payer partners. We're collecting now social driver information. I think that's where having such a strong analytics platform is so important. Risk segmentation becomes really important, so if we know patients are well, they're seeing their physician every year, they're taking their medications, they're controlled within their chronic disease, then there's a pathway for that. But if there are patients that we know are at risk for a readmission or are not adherent to their medication and seem to not be managing well then that's where we think about our ambulatory care management and then deploying some of the other resources, like again, a community health worker, which has been incredibly helpful especially when we need to make visits to patients’ home. But I think that's really where segmentation comes into play, because you're right, otherwise it becomes very overwhelming. But then it is sort of having a level of sophistication where you can sort of say, we've arrayed the population, we understand the risk segments, we know which provider groups they're working with, who may not be working or seeing a provider that we need to get them in with, but then deploying this whole array of pharmacy, care management teams, maybe our community partner teams, to sort of hopefully engage with patients at the right time at the right place. Because otherwise you're right it it's sort of how do you get your hands around this. And I have found it's usually not about one disease condition, it's really looking at more of that whole population. You know we say we want to do everything for everyone all the time and we I think we I think we want to do everything for people at the right time when they need it and I think being proactive is usually what I think sets apart like how is pop health different? Because we're using this information to really be proactive and reach out and not wait for somebody who's not managing because we have things like the frailty index and other risk scores so our goal is to also try to sort of anticipate what might happen in and intervene before it happens.

Well how can healthcare leverage community based organizations to improve those outcomes?

I think that's a double edged question because I think we often need to be engaging our health care organizations more intentionally about asking them what they need. I think thinking about what does it mean - you certainly we have the data - but what does it mean to improve health in this community? What would that look like? What would tell you what outcomes would tell you that we were improving health? So I think our community partners are incredibly important and if we think about you know what's driving someone's health, I think 20% of a patients overall health is what's derived from the medical services that are rendered to them. So the rest of that is social and physical environment, behavioral, and a little bit of genetics but really that kind of behavioral social emotional health, and then the physical environment is so key to that. And we can't solve all of the health care issues that are so broad based alone. So they are an incredibly important partner. I think it's everything from thinking about what we make investments in and sometimes they may not be directly healthcare related. They might be supporting a new housing development, like we've done here in Winston. It might be we're promoting the opening of a Federally Qualified Health Center which we have in and supported through our Wilkes Foundation, which means we're opening up another primary care access point for the community. It also might be investing of course with our local food bank partners, investing in school based programs, and then other partners that may focus certainly on social substance abuse and behavioral health, really helping support our partners there, because we also know we don't have the capacity or the workforce to also provide all of that care. So it they having that as whether it's part of a foundation, local Community Board, having our teams be present in their meetings or on their boards. But I think it is sort of rethinking what community investments mean and then using things like the CHNA and a needs assessment as a guideline of really determining this is what the health of the community, this is what it's saying is the highest and prioritized needs and making sure we're aligning with that.


As we're making investments in the community through food banks or school-based initiatives, are we able to quantify that investment to see the impact to the overall health of the population we're investing in?

That's a good question. I think sometimes you know when we look at some of the indicator data, the American Community Survey CDC data, I would say yes. But it's not always immediate. It sometimes can take two, three, five years to see an impact. And some of the challenges are so large and systemic, it could take decades. So that I think is always the balance of what are we making investments in and what is the return? Is it we're managing diabetes and we can show that we lowered A1C four 500 patients or is it we're working on childhood obesity and it's going to take decades before we see the rate of child obesity go down in a community? So that's so the answer is yes, but I also think that it sort of depends on the scope and scale, but also you know maybe defining early indicators. Knowing that some of those longer-term outcomes may take much longer. And I think that's a challenge for health systems, for funders and general, because we typically like to see those wins pretty quickly. We want to see results and some of these challenges are deep, have been in place for a very long time and will take a very long time before we can see real movement in that. But I think there are what I'd say leading indicators that yes we would definitely be looking for that.


Well Jennifer, one final question. What can a provider do right now to begin to address some of the needs of their rural patient population?


That's that is a good question. I think providers probably know there's you know they're seeing patients and families; they probably know across their practice what they're seeing. Whether maybe it's maybe it's something that's more straightforward like I have a lot of missed appointments and I need more support for transportation. I think connecting in, our goal I think for all of our practices, including rural is to have a care team connected to them, whether that's an RN navigator, social worker, community health worker. So making sure they're tapping into that and if there are resources that they're not aware of, taking advantage of that, but at the same time also sharing being part of some of these more think community social impact committees of helping prioritize where we're resourcing and making investments to support that. So I think that you know having a primary care medical home, you know, is such an important piece of what we're trying to do in general and pop health, that really being able to work with that team and take advantage of some of the things like we're doing with our find help resource hub, again, engaging with that care team, and then also telling us as pop health leaders we need more of X because this is actually what's really, these are the barriers for our patient to actually achieving optimal health is what I would say as well.


Well Jennifer Houlihan, thank you for that insight and thank you for joining us today on the move to value podcast

Thank you for having me

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