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Personalizing Patient Engagement to Address Population Needs
There are numerous reasons why a patient might forgo care, but many can be traced back to social determinants of health: limited resources, low health literacy, barriers to access… all can get in the way of good health and well-being. The care journey begins at patient outreach. Using quality reporting to understand disparities in care and remembering to consider race/ethnicity, gender identity, poverty level and education will help stratify population risks and identify opportunities, approaches and resources to support patients and ultimately determine their engagement. But leveraging quality reporting is just the start. We must also use demographic and social data embedded in dashboards and workflows to identify and address disparities, continually monitoring interventions to evaluate their effectiveness on the populations at highest risk for the lowest social and clinical screening rates.Let’s look at how patient engagement strategies can help a health care organization advance its health equity strategy and stay in touch with consumers to recognize their needs.
Modernize Communication Methods
Traditional methods of outreach are becoming less effective. Relying on phone calls to a patient’s home to establish contact prevents many patients from accessing care. Most people use a cell phone; only 40% of American households* have a landline. And today’s patients don’t have the time (especially during the workday) to play “phone tag” while trying to get an appointment.
Communicate Early and Often
A multi-step, multi-channel engagement strategy can help uncover SDOH issues and work to solve them over time. More frequent health care consumer engagement—from live phone calls and interactive voice response (IVR) to email and text messaging—is a great way to nurture connection and build trust with members and patients. The more comfortable a patient feels early in the relationship, the more receptive they may be to advice and help.
Make Communication Culturally and Linguistically Competent
One in five people living in the U.S. speak a language other than English at home. Communication difficulties that language barriers create have consistently shown to lead to decreased medication adherence, lower patient satisfaction and adverse health outcomes. They can also harm the patient-provider relationship, which has a ripple effect on patient health—and on the organization’s health, as well. In-language communication is critical for engaging and empowering patients to prioritize their health; ensuring they understand the care plan and the steps they need to take to get healthy is key.
- Linguistic competence: Providing readily available, culturally appropriate oral and written language services to limited English proficiency (LEP) members through such means as bilingual/bicultural staff, trained medical interpreters, and qualified translators.
- Cultural competence: A set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals that enables effective interactions in a cross-cultural framework.
- Cultural and Linguistic Competence: The ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by the patient to the health care encounter.
Prioritize Post-Discharge Support and Engagement
After a patient is discharged from a hospital or care facility, reviewing and addressing SDOH can help prevent ED visits and inpatient readmissions. Does the patient have a strong social network, access to healthy food and the ability to manage medications? Asking questions about lifestyle and resources and offering solutions within a patient’s reach can promote positive outcomes and keep costs low for all. But although it sounds like common sense, this step is often overlooked by both health plans and clinicians.
Personalized care based on population needs leads to effective engagement methods and consistent health outcomes. Using strategies like those listed below, which consider social and lifestyle, can help advance initiatives to close gaps in clinical and social care:
- Preventive care.
- Care management programs.
- Patient outreach campaigns.
- Automated decision support tools.
- Appropriate level of social and clinical support.
What do you think?
1. How has your organization integrated patient outreach into its health equity and SDOH strategies?
2. Has your organization assessed the workforce, tools, resources and systems for diversity and cultural contexts of the individuals and communities it serves?
3. What clinical or operational challenges should stakeholders consider when personalizing care and engagement and monitoring strategy effectiveness?
Vanessa Guzman,CEO,SmartRise Health
Vanessa Guzman is an expert in population health strategies, including patient and physician engagement strategies, clinical reporting, health IT and quality management models, and CEO at SmartRise Health. With almost 15 years of industry experience, she works closely with health systems, Accountable Care Organizations (ACOs), technology, and SDOH partners to collaborate in implementing data-driven tools, clinical infrastructures, and community partnerships to promote wellness and improve patient health outcomes.
Vanessa served as the Associate Vice President at the Montefiore Health System, a top-performing ACO in the country, overseeing physician partnerships, population health and quality improvement, and health information technology.