Making an impact between clinical visits to improve population health

Dr. Calie Santana, senior medical principal for innovation at Evernorth, recently spoke at this year’s Population Health Colloquium about partnering with health plans and employers to solve health care’s biggest challenges – namely the social determinants of health which influence 80% of the health care outcome.

While providing care is a key part of improving population health, those services contribute to only 20% of health outcomes. The rest is determined by people’s behaviors along with the social, economic, and environmental conditions in which they live and work. For many people, these social determinants of health can become obstacles to achieving and maintaining good health.

“Health care companies need to be more aware and involved in addressing the other 80% of health factors that occur in between and around the clinical encounters if they really want to make a difference in the lives they serve,” said Dr. Calie Santana, senior medical principal for innovation at Evernorth.

Resolving even a few contributing social issues can be a big win for a patient’s health, said Dr. Santana, a practicing internal medicine physician, and a leading expert in leveraging data analytics to develop care delivery solutions for health systems and multi-specialty groups, who joined Evernorth in April. Dr. Santana spoke about partnering with health plans and employers to solve health care’s biggest challenges during a presentation at this year’s Population Health Colloquium, the leading forum on population health innovations.

Using data to identify areas of opportunity

Data is paramount to developing strategies to better address population health, Santana said. As an example, she described how the Evernorth Social Determinants Index (SDI) leverages publicly available data to help clients understand the key social needs that are affecting the populations they serve. The index uses 22 distinct data measures across six key social domains to identify care gaps and health disparities in a specific ZIP code or census tract.

Evernorth correlates these SDI findings with its medical and pharmacy claims to get a sense of the clinical issues that correspond to social determinants of health in the area. “This gives our clients a more detailed, nuanced picture of their population’s particular needs so we are better able to co-create the solutions necessary to address them,” she said, adding that meeting these social needs can help prevent unnecessary health care burdens and additional associated costs.

Co-creating solutions with clients

After Evernorth shares data insights with clients, they work together to identify strategies to address the health and social needs of the client’s populations. “This can involve either deploying existing solutions or co-creating new solutions that are connected, convenient, and compatible to each individual’s care,” Dr. Santana said. A team of Evernorth data scientists, IT analysts, program developers, and researchers work on developing solutions. They are supported by clinical physicians, nutritionists, behavioral health specialists, pharmacists, and nurses who inform and deploy new solutions.

Solutions can include guided and dedicated support programs in which Evernorth care navigators help reduce delays and confusion in a patient’s care plan, copay adjustments to improve affordability, or onsite clinicians who provide access to care where people work. One example Dr. Santana shared involved an employer in a rural area with several workers living with diabetes who were unable to attend regular doctor visits to manage their condition. Evernorth and the employer developed a plan to hire a pharmacist at the company’s onsite clinic who can check hemoglobin A1C levels and counsel workers living with diabetes. This resulted in a significant reduction in average hemoglobin A1C levels among the worker population and a six-figure savings in overall health care costs.

Evernorth also facilitates virtual and digital care options to help improve access. These are provided via telehealth and by vetting key digital applications that can achieve better health outcomes for employees and health plan members with certain conditions.

“Many of our clients want to co-develop solutions with us,” Dr. Santana said. “It’s a wonderful step in our progress to improving population health.”

Opening connections to clinical expertise

During her presentation, Dr. Santana shared her experience of caring for her elderly parents, spending 10 years helping them understand and navigate the health care system to find the care options they needed, as well as addressing any side effects of treatment so they could continue to experience a good quality of life.

Of course, not everyone has a family member who is a physician that they can turn to for expert help in managing their care. So Dr. Santana recommends solutions that connect patients to clinical experts for consultation whenever they need it, adding that these connections should be convenient for both the experts and the patient – such as meeting over the phone, via telehealth, by texting, or through digital applications.

This access can be especially helpful for those who live in rural communities and would need to travel long distances to access necessary care in person. As a hypothetical example, she described a woman recently diagnosed with complex cancer who was unable to travel to get a second opinion on her care regime. Fortunately, Evernorth can help patients in that situation with its Oncology Consult Service, which would connect their treating oncologist to a National Cancer Institute-designated specialist who can review the patient’s diagnosis and treatment plan and give an opinion as to the best course of action.

Dr. Santana also listed additional expert connections to assist this hypothetical patient, including telephone consultations from a specialty pharmacist in Accredo’s Therapeutic Resource Center (TRC) for patients with cancer, to help her better understand her medication regimen. The nurse or pharmacist from the TRC team can also listen for signs of the patient feeling stressed, depressed, or overwhelmed. In such a case, they would connect the patient to an Accredo social worker, who would conduct a full behavioral health assessment and can discuss therapy options available, including virtual visits via MDLIVE if they are included in her plan.

“With all of that support at the ready, she would be able to maximize the effectiveness of her cancer care and her overall health,” she said.

Making health part of the flow of life

Many of the social challenges that patients face provide opportunities for Evernorth and its clients to find new ways to overcome these barriers, enabling people to maximize the healing potential of their care and achieve the best health possible.

“In times when life gets in the way of health, we aim to transform that situation so health can be natural part of the flow of life,” she said.

(Note: Some of the quotes in this article were lightly edited for clarity.)

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