Population Health

Questions remain around a host of issues pertaining to health, notably reimbursement and ensuring that the models and systems implemented drive access and quality gains that justify costs. But few in healthcare would dispute that virtual health has earned a permanent place in care delivery following its swift ascent in 2020.

Telehealth is not and never could be a pure substitute for in-person visits, according to Thom Bales, U.S. health services sector lead at PwC. But, he says, “providers can look at it as an essential lever for increasing access to care, efficiency and clinician productivity. All health systems and physician groups need to make sure they have competitive capabilities in this space.”  

Indeed, when it comes to population health, it’s hard to disagree with the argument that telehealth “makes care more equitable and accessible to the 89% of U.S. adults and 78% of adults globally who own a smartphone, including those in medically underserved communities,” as Robert Pearl, former CEO of the Permanente Group, Oakland, Calif., and Bryan Wayling of Intermountain Healthcare, Salt Lake City, write in the May/June 2022 issue of Harvard Business Review. “Any nation seeking to raise health care quality, increase access and lower costs should be expanding, not contracting, the use of virtual care,” they say. 

What Virtual Health Can Do

Virtual health offers major opportunities in five areas, according to Pearl and Wayling, all with implications for population health: reducing unnecessary and expensive ED visits, stemming the chronic disease crisis, reducing disparities in care, improving access to specialty care and connecting patients with the doctors most knowledgeable about a particular disease regardless of geographic location. They estimate that full implementation of telehealth services in these areas would improve clinical quality nationwide by 20%, increase access to care by 20% and reduce health care spending by 15% to 20%. 

Bales believes the effective implementation of these services for population health management revolves as much around traditional workforce management involving decisions regarding scheduling and productivity as it does around digital technology. This is because technology has progressed to a place where many organizations already have telehealth capabilities embedded in their EHRs. 

He notes that the trend toward physician employment can help organizations in this regard because the employment structure lends itself more readily to rallying groups of clinicians around specific population health goals. 

A Necessary Part of Patient Care 

Though telehealth utilization rates remain higher than before the pandemic, Centers for Medicare & Medicaid Services data show decreases in most areas other than behavioral health services since telehealth’s precipitous rise with COVID-19’s onset. 

Still, virtual health remains “a necessary and urgently needed modality of care,” stresses Kyle Zebley, senior vice president of public policy at the American Telemedicine Association, in a statement in March, citing virtual health’s power to remove geographic barriers, expand clinically appropriate options and help clinicians reach more people more efficiently.

Bales sees a bright future for virtual services in population health management that extends beyond primary care and behavioral health to specialty care, hospital at home and home care platforms, and as a vehicle for monitoring medication adherence, particularly among polypharmacy populations. Some of that is already happening, but telehealth still holds great potential, he says. 

“Virtual health needs to be part of the equation for every organization around improving quality and affordability and allowing clinicians to practice more productively at the top of their license,” he says. 

Yale New Haven Health System: Building on Lessons From a Crisis 

As a system affiliated with a major medical school, Yale New Haven Health is something of an early adopter in the use of virtual services for population health management. The five-hospital system had invested in telehealth before the pandemic and strengthened its use during the pandemic, according to Polly VanderWoude, FACHE, executive director, population health and clinical integration.

“The fact that we had a commitment to technology-enabled care pre-COVID and were already building capabilities internally positioned us to rapidly deploy virtual services to keep our physicians connected with their patients,” she says.

Yale New Haven Health set up a national COVID-19 call center that fielded questions and triaged patients, as well as a home-based monitoring program that included, among other things, providing pulse oximeters to patients for home use and daily logging of vital signs into the patient portal. That home-based program is “an early example of how we were able to use virtual technology to keep patients safe and in their homes while reducing the burden on our care teams and care sites,” she says. 

The system is spreading those same clinical triage capabilities across its primary care sites and post-discharge outreach teams for many other conditions. “The concept is to use the same types of algorithms, tools and home assessments developed during the pandemic to direct patients to the right site of care or enable them to stay home,” VanderWoude says. To date, these programs have generated favorable satisfaction ratings and engagement with a protocol of outreach phone calls to patients following hospital discharge to schedule follow-up visits, resolve prescription and medication issues, and provide clinical triage if necessary.

Among the options available to patients is receiving an on-demand virtual visit. “What was originally stood up as a community resource for COVID is now the backbone of how we triage and stay connected with patients,” she says. 

The system offers a digital cognitive behavioral therapy tool for patients who have a referral from their primary care physicians. Brought to the population health team through the YNHH Center for Health Innovation, the novel technology holds promise as a cost and resource savings strategy in an area of high demand. A third of patients showed 50% improvements on Patient Health Questionnaire measures of mental health following engagement with the tool, VanderWoude reports. 

In addition, after an initial pilot for patients with hypertension, YNHH is expanding a remote patient monitoring program to include patients with diabetes and congestive heart failure patients, as well. “We see the ability to keep patients in their homes using technology-enabled virtual services as a critical part of increasing access to care,” she says.
 
VanderWoude stresses the importance of remaining sensitive to the needs of front-line clinicians in virtual health services trials and rollouts. “One of our biggest lessons learned was the value of ongoing communication with clinicians about how a service will help them care for their patients while relieving some of their clinical burden; having front-line clinicians engaged in our project teams has been critical to ensuring programs that are sensitive to how they and their patients experience digital health offerings,” she says.

Kaweah Health: Generating Access for a Population in Need

With eight hospital campuses and a network of rural health clinics spanning Tulare County and surrounding areas, public nonprofit Kaweah Health, Visalia, is the largest healthcare district in California as well as the county’s leading acute care provider. Located in the heavily agricultural Central Valley, the health system serves one of California’s largest low-income populations, including thousands of migrant farm workers. It ranks highest in the state in percentage of patients covered by Medi-Cal. 

The system had already been strategizing about telehealth and reviewing vendors for a year and a half when the pandemic began, says Ryan J. Gates, PharmD, chief population health officer, and an ACHE Member. But those solutions required patients to set up an account before they could access the platform. In the heat of a crisis, “those options presented barriers that were not going to work for our community,” Gates says. 

Instead, as the pandemic loomed, the system chose a simple, affordable solution that essentially created a HIPAA-compliant FaceTime. “We had our first telehealth visit on that platform within seven days of the pandemic washing up on our shores,” he says. 

Reflecting trends across the country, more than 40% of Kaweah Health’s outpatient visits were virtual at the pandemic’s peak. Today, that figure hovers between 10% and 15%. To mine telehealth’s potential and raise that number now that the dust has settled from the pandemic, the system is developing virtual services targeted to its underserved population’s most pressing needs. 

One of those needs is hypertension. Another is diabetes, which has an incidence rate in Tulare County that is double the state average. “For chronic diseases that are intensely managed with high-risk medications, telehealth can play a big role in getting patients controlled faster and safer,” Gates says. Despite the area’s considerable number of low-income residents, the fact that almost everyone in the service area has a cell phone works in the system’s favor. 

The first step has been identifying which types of visits and follow-up can best be handled virtually. “It’s all about program design and making sure the patient is deeply engaged in their care at home,” Gates says. 

While the initial training around blood glucose monitoring and insulin injections for diabetes patients must be done in person, “the next three visits can and should be convenient, quick check-ins,” he says. Telehealth is a natural for those follow-ups and offers a huge advantage in an area like Tulare County, in which transportation is a significant problem and many people don’t get paid for time off from work. 

Similarly, for hypertension, though in-person training on collecting an accurate blood pressure reading on a home device is needed, telehealth’s convenience makes it a shoo-in for this patient population as well, according to Gates. 

To develop programs around these and other population-based virtual services, Kaweah Health has begun working with a solution chosen for its ease in connecting with Bluetooth devices for in-home monitoring and sending data to the EHR. 

The system has partnered with health plans to provide remote monitoring devices. “The level of engagement needed for remote monitoring requires patients who are fairly tech-savvy, but we know it’s possible to achieve that,” he says. 

Though it’s poised to move ahead, like many organizations, the system is grappling with balancing the costs of virtual technology against the risks associated with lingering uncertainties around reimbursement and utilization, Gates says. “Should we pause before we make massive investments in tele-infrastructure?” he says. “Will the investment deliver a return that improves health? That’s why we feel a sense of urgency to not let up on refining and integrating virtual services that will produce results at the population level.” 

Amid issues of equity, a workforce shortage, an older, sicker baby boom generation and the growing burden of chronic disease, virtual health stands out as a tool with huge promise. Clarity around reimbursement and knowing how to bring that promise to fruition remain a work in progress. 

Susan Birk is a Chicago-based freelance writer specializing in healthcare.