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Improving Population Health Management in Rural Communities

By 07.10.23 Red stethoscope on wood
Reading time: 7 minutes

Structured and comprehensive patient population health management, coupled with access to healthcare and wellness services, are tantamount to achieving and maintaining good health. For populations outside the fray of large urban centers, obtaining these things can be a daunting challenge.

Rural and small community residents frequently incur a myriad of obstacles and unending barriers to access and receiving services that align to and meet their care needs. Core services such as primary care, specialty care, dental care, behavioral health, public health services, and emergency care are often unable to be secured, and if secured, are not done so in a timely manner.

Impact from this means that the ability to maintain overall physical, social, and mental health status is impeded. Disease prevention and detection, diagnosis, and treatment of illness are impeded, leading to reductions in quality of life, mitigation of preventable deaths, and overall life expectancy. 

Even in instances where there may exist adequate healthcare services to meet supply/demand modeling in the community, other factors hinder access to care: financial capability to pay for services needed or insurance coverage; healthcare literacy and language barriers; privacy concerns; trust in the capabilities of the local providers/caregivers to achieve desired clinical outcomes; transportation issues; adequate time off to commute and have services performed; and general access to the right social and support services.

Service types that are difficult to access in rural and small communities 

The supply of providers per capita, both in primary care and especially in specialty care, is lower in rural and small communities compared to urban areas. This disparity creates difficulties for patients in these areas as necessary healthcare service types become difficult for patients to access in a timely and efficient manner, leading them to forgo care needs altogether. These contributing factors result in unmet healthcare needs and degradation in general health and wellness. 

Rural and small communities require access to the appropriate medical care. Key areas of service that are most commonly difficult for rural and small communities to access include:

  • Primary and sub-specialty care
  • Reproductive, obstetric, and maternal health services
  • Mental health services
  • Palliative care and hospice services
  • Oral health services
  • Home health
  • Substance use disorder services

In conjunction with the above, healthcare facility closure and service discontinuations are also impacting access to care in rural and small communities, further complicating Population Health Management efforts.

Strategies to improve patient population health management and access to care 

The shift in population health management and access to care requirements, ranging from risk-based contracting to pay-for-performance arrangements, has enabled healthcare providers to receive enhanced financial incentives for focus and delivery of preventive services, treatment of patients, and improved maintenance or reduction in recurrence of condition types/codes. In addition, there is financial incentive for structured and comprehensive tracking of care across the continuum and improving the overall lifecycle management of patients. 

All of this is driving healthcare providers and systems to invest heavily in the required strategies and technologies to proactively manage patients’ needs rather than reactively address them. As such, rural and small community healthcare providers are more focused than ever on developing and deploying population health management programs and improved access models. However, they are often impeded from fully executing and delivering on these programs and models due to limited budgets and staff.

 Key delivery models that are now deploying include:

  • The rural emergency hospital
    • A new Medicare provider type designed to maintain access to emergency and outpatient care in rural areas and small communities
  • Freestanding emergency departments (FSEDs)
    • Facilities that are structurally separate and distinct from a hospital, providing easily accessible emergency care
  • Community paramedicine and mobile-integrated health programs
    • Paramedics and EMTs operate in expanded roles to assist with healthcare services for those in need without duplication of available services in the community
  • Community health workers (CHWs)
    • Deliver healthcare access by leveraging CHWs as a liaison between healthcare providers and rural residents to ensure their healthcare needs are met
  • Expanded accountable care organizations (ACOs) and patient-centered medical homes (PCMHs)
    • Extend access to primary care services through a variety of medical home and care coordination programs
  • Affiliation with larger systems or networks
    • Expansion and maintenance of healthcare access, improving clinical outcomes and financial viability of rural and small community facilities through additional resources and infrastructure and ability to offer new or expanded services
    • Access to expanded to technology, staff/staff recruitment, group purchasing, increased access to healthcare and operational services, value-based payment models, and improved performance
  •  Workforce management improvements
    • Leveraging new provider types, top-of-license operating models, interprofessional teams, and creative scheduling offering clinic time outside of normal hours of operation
  • Telehealth
    • Expanded access to see specialists in a timely manner without the impediment of long travel distances or access to transportation
    • Rural access to broadband services is currently largest impediment to broad-based adoption and expansion 
  • Private foundations
    • Leveraging foundations for funding transportation services, improving workforce, investment in safety net providers and programs, grants to implement innovative access and care delivery models, research funding

Effectively managing patients, especially those with complex conditions dealing with limited access to required healthcare services, requires healthcare providers to change the traditional fee-for-service care delivery model and workflows. Given the propensity for patients to have continuing encounter types like ER visits or hospital stays, healthcare providers in rural and small communities need to be more creative and leverage team-based collaborative methodologies.

Leveraging technology for patient population health management and access models

Building and maintaining a consistent approach to patient population health management and access modeling means having an approach that is supported with the right data and the right technologies. This infrastructure is no longer a want, but an imperative for rural and small community healthcare providers to drive the correct patient population health management and access models for their patient populations.

A key data and technology need is leveraging EMRs/EHRs in concert with patient population health management, CRM, and advanced data analytics tech stacks. The aggregation, integration, and continuity of data across these systems allows for the appropriate level of visualization, measurement, and management. This drives the appropriate level of care needed, timing for delivery, and engagement with patients to yield best clinical outcomes and maintain the overall health and wellness of the community.

Technology and data are the foundation for these programs, models, and processes, as well as the measurement and tracking of progress and best practices. Key areas where technology and data serve rural and small community healthcare providers are as follows:

  • Patient population program management
  • Patient attribution
  • Stratifying patients by risk and risk scoring
  • Staff capacity management, hiring, and reallocation
  • Maximizing population health reimbursements and pay-for-performance
  • Change management and acceptance of new workflows
  • Enhanced and customized patient engagement
  • Care coordination across the continuum
  • Optimized access modeling
  • Care quality and outcomes tracking
  • Communication of outcomes and best practices

Care gap closure and preventive maintenance care coordination are examples of how a rural or small community healthcare provider could leverage CRM and patient population management platforms in concert with their EMR/EHR. A CRM system like Salesforce with Health Cloud and Marketing Cloud can work with patient population management software and the EMR/EHR to create seamless identification and extraction of patient population health chase lists — defined by the healthcare system and aligned to condition codes, segmentation, and cohorts — from systems of record based on care gaps/care coordination needs. 

The Salesforce platform can identify and facilitate engagement through a patient outreach preference channel, with personalized messaging and cadence to drive desired patient engagement and compliance on care gap closure, care directives and preventive maintenance, general wellness, and required visit frequency. Some of the benefits to the rural and small community provider are:

  • Drive efficiency in the process flow through automation
  • Bring a concierge fit and feel to patient communications 
  • Increase response rates for outreach
  • Improve scheduling conversation rates and presentation rates 
  • Improve clinical outcomes 
  • Track and manage all aspects of the patient lifecycle and maximize staffing and reimbursement rates with robust data visualization and reporting
  • Improve and drive targeted patient education campaigns
  • Promote patient portal enrollment and utilization
  • Optimize telehealth capabilities and experience
  • Streamline and mitigate patient slotting and care coordination issues
  • Patient redirection to appropriate care sites
  • Track population health impact 

The platform, in concert with the EMR/EHR and any other system of record, allows a healthcare provider to create a unique POV to better understand their patients and build unique journeys to engage and guide them through all their interactions with the provider. Most importantly, it allows this to be done in a manner that can and does address all unique needs of the patient and their support network.

Cost factors and new government funding programs

The biggest obstacle to rural and small community healthcare providers to implement and maintain programmatic management and maintenance of patient population health management access models is the cost. Shoestring budgets and limited capacity to increase staffing models make it impossible for these healthcare providers to achieve forward progress.

Recent funding has been extended from the federal government in the form of the Community Health Access and Rural Transformation (CHART) and the newly proposed FY2024 Federal Healthcare budget proposals, which include critical investments to increase rural and small community healthcare access, drive workforce recruitment, and address health disparities.

Some of these budget proposals include $30M to help sustain rural and small community hospitals, of which $20M is targeted for the Rural Hospital Stabilization Pilot Program. This program allows rural and small community hospitals to enhance/expand needed service lines to improve long-term hospital viability. $10M is for the new Financial and Community Sustainability for At-Risk Rural and Small Community Hospital Program. This program will target qualifying hospitals at risk for imminent closure in order to provide technical assistance.

In addition, $10M has been budgeted for the Rural Health Clinic Behavioral Health Initiative. This initiative will allow clinics in rural and small community areas where there are no existing behavioral health providers to fund the salary of a behavioral health provider, address provider burnout, and expand services availability for mental health screenings, counseling, and therapy.

Rural and small community healthcare providers should inquire and verify their eligibility to established and newly proposed funding in the FY2024 budget. These funds, if available and qualification status is met, can subsidize technical, operational, and clinical investments in tools, technology systems, and workforce (clinical/operational) to improve patient engagement, care access, care delivery, capacity management, and overall patient population health and access model management.

The Silverline differentiator

Healthcare systems must recognize that the providers referring into the system are as much of a consumer as the patient. By implementing Salesforce to assist with referral management, providers open up market share opportunities and generate positive impacts across the continuum of care. The patients benefit from getting the referral to the right provider, with the ability to get it scheduled in the right time frame for the right service delivery and, ultimately, the right clinical outcome.

Unlock the ability to ensure effective and efficient management of the referral lifecycle with Silverline. We provide strategy, advisory, technical implementation, and ongoing managed services to meet your current and future needs and to achieve maximum value with the Salesforce platform. Find out how we can help your healthcare organization.

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