Is your life situation affecting your health?

You may have heard the term ‘population health’ coming up in discussions around healthcare. Population health is exactly what it sounds like – keeping the entire population of a region healthy. Doctors figure prominently in the formula, working as part of a team to keep the community healthy in a cost-effective way. Oftentimes, this means sending case workers and others outside the four walls of the hospital or clinic and reaching patients where they are.

It’s not only the right thing to do, but also something that healthcare payers like MassHealth actually require, according to Kumara Sidhartha, MD, MPH, Medical Director of the Cape Cod Healthcare Accountable Care Organization (CCHC ACO) also known as the physician hospital organization (PHO). The PHO comprises of a partnership between Cape Cod Healthcare and Cape Cod Preferred Physicians and the organization is set up to work with insurance companies, including commercial and MassHealth. The PHO also partners with Duffy Health Center and Outer Cape Health Services in the ACO model to manage the Cape’s MassHealth population.

“The key element to population health is really a lot of care coordination and delivering the care in a team-based approach,” said Gemma Jones, director of PHO Clinical Integration & Clinical Operations at Cape Cod Healthcare ACO. “The team is comprised of primary care, specialists, community-based services and Helping Hands which includes care navigators. What we do is we basically work with the patients’ health and wellness trajectory, so we help pull in the different community resources to address the needs that they may have.”

Helping Hands includes clinical case managers, a clinical pharmacist and five ‘care navigators’ who guide patients in finding the different resources and coach them to become and stay healthy. There is one navigator at each hospital Emergency Department and three that meet our patients out in the community. Their focus is on what are known as the ‘social determinants of health.’ Healthy People 2020 groups the social determinants of health into five key areas: economic stability, education, social and community context, health and health care and lastly neighborhood and built environment. The key areas the navigators are addressing in our community are things like housing instability, food insecurity, access to transportation, and employment.

“We are working with our physician partners with the goal of getting to the highest quality of care that is patient-centered and takes a whole person approach to health,” Dr. Sidhartha explained. “When we say ‘whole person,’ we are looking at not just the mind/body but also looking at their social needs and the other barriers that come in the way of their health.”

One Patient’s Case

Healthcare navigator Cheryl Kramer works with patients in the community. She said one patient’s experience perfectly sums up the many different aspects of her job – and demonstrates the value of the program. The patient was referred to her by one of Cape Cod Healthcare ACO’s behavioral health case managers. When Kramer met the patient last fall, the woman had spent months in and out of a psychiatric hospital trying to get stable.

Once she was discharged from the hospital, she had no money, no food, no heat or electricity and no phone. She also did not have access to transportation and was physically and mentally unable to work. Additionally, the house she had been living in was about to be repossessed by the bank.

Despite the sheer number of obstacles this patient had, Kramer was able to guide her, one step at a time. The first thing she was able to do was get the patient’s electricity and gas turned back on.

“We were able to work with her primary care physician to get a letter written to submit to the gas and the electric company to put a stay on that so that she would get electricity because of her medical needs,” she said.

Kramer also found a company to service the furnace, which would not turn on. Next, she helped the woman apply for food stamps and emergency cash through the Department of Transitional Assistance. They visited local food pantries as well.

“For the first couple of weeks, I pretty much met with her at her house every day,” Kramer said. “We ordered a SafeLink phone for her, which is free for people who are on MassHealth. We applied for Social Security disability. Working with her doctor, we were able to set up PT-1 rides for her. Now, she can get to her primary care physician. Our behavioral health nurse set her up with a psychiatrist. We were also able to apply for Department of Mental Health services for her, because that’s a huge piece for her.”

When it became apparent that the patient could not afford to stay in her home, Kramer helped her navigate the sale of the house and set up a trust with the money that will benefit her throughout her life. She was also able to find transitional housing and get her involved in daily programming so she could have opportunities to see other people.

The patient found several outside activities she enjoys and is exploring the notion of getting a job someday. When Kramer saw her recently, she was thriving.

“Because she was willing to work with us, we were able to get her connected to the right services and programs and now I don’t have to see her every day,” Kramer said. “I don’t even have to see her every week. I check in with her every couple of weeks. That’s exactly the way it should be. She’s living her life. She doesn’t need our support, but she also knows that if something comes up, I’m a phone call or a text away.”

The story would have been much different if the patient did not have the support of a Healthcare Navigator and team.

“Honestly, if we had not been there, she would have sat in that house and probably spiraled right back into a hospital - if somebody had come and found her. And that’s a scary thought,” Kramer said.

Helping Patients Navigate

The social factors of health are becoming a much larger focus in the current era of healthcare, Dr. Sidhartha said. Even though the data show some variability, it’s estimated that between 10 to 15 percent of health outcomes are related to the medical care provided and the remainder is largely related to the patient’s behavioral changes and living environment that either encourages or discourages healthy behaviors.

“In case management, what we do is try to get the patient to navigate their world to find resources that are out there in the community,” Dr. Sidhartha said. “We are establishing partnerships with community entities so that we can more effectively help patients meet their healthcare needs.”

An example is the Cape Cod Regional Transportation Authority (RTA). Cape Cod Healthcare has worked with the RTA to increase the number of bus stops at essential areas for patients so they can get to their medical appointments. The RTA also now has a dedicated telephone line for clients of its PT-1 transportation program, which provides rides to medical appointments for people on MassHealth who don’t have any transportation.

“In today’s healthcare landscape, patients’ needs are more complex and patients’ diseases are more complicated,” Dr. Sidhartha said. “Addressing that more effectively in a timely manner requires looking beyond one-on-one interaction between the physician and the patient inside the four walls of a healthcare building. It requires a much broader team-based approach where not only is the physician teaming up with specialists and the case managers and the care navigators, but also teaming up with other community partners beyond the four walls of healthcare.”