By Melinda Young
It takes a village to improve population health and whole person care. The village includes the public health system, which can be led by case management or a care coordination team.
Populations that experience health inequities can benefit from the whole-person approach, particularly when hospitals form public health partnerships and use telehealth at discharge. For example, Black patients with Medicare reported lower inpatient and readmission rates when they were treated in hospitals that partnered with public health systems, according to recent research.1
“We need a whole village to work together because it’s not just healthcare, it’s also social care,” says Jie Chen, PhD, lead study author and a professor and director at the Hospital And Public health interdisciPlinarY research (HAPPY) Lab at the University of Maryland. “We want to start with prevention, making sure the person gets timely care in the right place. Patients need care coordination, and they need medical care, follow-ups, housing services, education programs, [and] nutrition programs.”
Whole-person care requires all these different specialties to work together. The first step is to use health information technology systems to enable successful integration and care coordination between hospitals, public health systems, and community providers and organizations.
Chen and colleagues studied follow-up care provided to patients. “We need more clinical evidence so we can convince the policymakers [to initiate] the integration,” she says. “We have the HAPPY Lab to investigate how we can integrate all the partnerships. This starts with local health departments, which are central in the community.”
This whole-village, whole-person approach needs integration between hospitals and community partners. The team can take the role of organizing care and speaking with patients, and hospitals can help the team find the right physicians to help patients in the community.
Local health departments are critical to a successful integration. “We’ve identified the local health department’s role as significantly improving the quality of care,” Chen says.
Focusing on integrating behavioral and mental health also is important. “For instance, there is a reduction of preventable hospitalizations due to depression because care coordination, educational programs, and mental health can reduce hospitalizations,” Chen explains.
People need access to accessible and affordable care, even if they lack insurance coverage for medical and mental healthcare. Those without insurance often report more pronounced mental health issues, Chen notes.
Patients Fear Stigma
Social stigma also is a barrier to improving patients’ mental health. “Sometimes, people don’t [understand] depression, and they’ll say, ‘You’re crazy,’” Chen says. “There is social stigma. Some immigrants will say, ‘I don’t want my employer to know I’m depressed.’” Mental and behavioral health issues exist across all populations, as does stigma for those experiencing these problems and for those seeking professional help, she adds.
When patients face stigma and access barriers, they are less likely to receive necessary mental and behavioral health screening and treatment. This is true for immigrant groups and other populations that face discrimination and care disparities.
A care coordination team should review disparities in their community and establish long-term relationships with patients to help them access the medical and mental healthcare they need, Chen says.
Another way to address health disparities is to improve communication between hospitals, patients, community providers, and organizations. “A communication data platform is very important so people can exchange data in a timely way,” Chen notes. Post-discharge follow-up and care coordination also is important, she adds.
Even with electronic health records, more communication sharing is needed. “We want to have measures on people’s social needs so we can design a patient-centered program,” Chen explains. “This is so care can be more timely. You can encourage patients to follow up and improve patient engagement.”
Population health and care coordination initiatives also should address informal care, including how family caregivers are taking on much of the burden of patients’ healthcare. These caregivers need to prioritize their own physical and mental health as well.
“There’s a tremendous need for caregivers to take care of themselves,” Chen says. “They can have depression and anxiety.”
The COVID-19 pandemic created a substantial burden for caregivers. Care coordination teams should not neglect this critical population.
Much of the change will require payment reform to motivate physicians and other providers to continue evidence-based practice for telehealth, which is one way to alleviate disparities. “We need to encourage care coordination and encourage doctors to work with the team to focus on whole-person care,” Chen says.
But case managers, care coordinators, physicians, and nurses will be most effective in addressing all the issues faced in whole-person care once payers cover their time and effort.
“We found that hospitals that received funding, and who had established care coordination and had a partnership with community stakeholders, had a reduction in cost per patient for Medicare, and [alleviated] disparity,” Chen says. “People say if you hand everyone [more] healthcare, it may increase expenditures, but that’s not necessarily true. Maybe we could improve healthcare equity and set other goals. Evidence shows it can work.”
Underserved communities and patients could benefit from stronger infrastructure that supports care coordination and a focus on whole-person care. Research shows underserved communities benefit when hospitals partner with public health systems and use telehealth services as part of care coordination.1
REFERENCE
- Chen J, Spencer MR, Buchongo P. Strengthening the public health partnership and telehealth infrastructure to reduce health care disparities. Popul Health Manag 2022;25:814-821.
It takes a village to improve population health and whole person care. The village includes the public health system, which can be led by case management or a care coordination team. Populations that experience health inequities can benefit from the whole-person approach, particularly when hospitals form public health partnerships and use telehealth at discharge.
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