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The Art and Heart of Population Health

November 11, 2015
Like all relationships, building rapport and trust are critical first steps.
Dawn Milstead

This article originally appeared on Medical Practice Insider. 

Let me begin by looking at engagement and outreach from the perspective of a fictional patient: Mrs. Ellen Hughes.

She is 67-years old, a bit overweight. She's an asthmatic who regularly sees her primary care physician but still ends up in her hospital's Emergency Department several times a year. To her doctor and her hospital, she is a patient; to her health plan, she is a member; and to her employer, she is an employee – all of whom want to intervene to improve her health and the associated costs of caring for her, but with different approaches and foci. 

Mrs. Hughes is likely being bombarded with information and outreach. I can imagine her phone ringing multiple times a week with well-intended but uncoordinated calls from her health plan, her doctor, her hospital, and even her employer. Each has little to no insight into what the others are doing, creating redundancy and unnecessary costs in the system and leaving her confused, perhaps even frustrated enough to alienate her from the very healthcare system that is working so hard to help her. 

I know we can do better for Mrs. Hughes and the many others like her, and it starts with everyone viewing her as a consumer and coordinating the care and outreach she needs to achieve improved health outcomes. 

The most robust analytics solutions aggregate data from multiple sources – claims, clinical, EMR, benefits, demographic, even patient-generated data from Fitbits and other wearables - to create a consistent, 360-degree view of the consumer. Equipped with this integrated, more holistic view of Mrs. Hughes, the engagement efforts of the health plan, doctor, hospital, and employer should be able to be connected and coordinated. 

By organizing the clinical interventions and using Mrs. Hughes' preferences to inform their delivery, she is much more likely to become engaged in her health. As a clinician, I have observed what countless studies have confirmed – when consumers like Mrs. Hughes are informed, empowered, and engaged in their health, outcomes improve.  Health costs also should be impacted, and that, in turn, helps all constituents in the healthcare delivery system achieve the Triple Aim on behalf of Mrs. Hughes and all consumers.

Undoubtedly, the underlying analytics and insights platforms are critical to meaningful consumer engagement and ultimately to population health improvement, and today's innovative solutions facilitate much more personalized, holistic, and coordinated engagement than was previously possible. But as one who began her career as a case manager and has led thousands of case managers during my career, I know that the people and the best practices they've developed after years of working directly with patients are just as important as the technology and software.

The people who engage consumers in their health on behalf of health plans, physicians, hospitals, and employers typically have titles like case manager, disease manager, care coordinator, and health coach.  But regardless of their title, they are charged with the same job: engagement and ultimately activating consumers to become involved in improving their own health.

It all begins with creating a unique and individualized relationship with Mrs. Hughes and every other healthcare consumer. Like all relationships, building rapport and trust are critical first steps.  Transparency and language matter too.  As one of my case managers said best, "Consumers can tell through the phone if I'm smiling when I call them.  I also need to let them know who I am, who my employer is, and why I'm calling." Demonstrating compassion and consistency are also important.  When I walk through the section of my office where the case and disease managers work, I often hear the words, "It's me again."

Excellent listening skills are critical.  The most effective engagement staff begin their conversations with questions like, "How are you doing?" and "How can I help?" They then stop talking and wait for a response, often enduring silence before the truth comes forward.  Sometimes it's important to identify common ground and reveal that they too are human and have struggles, "I have a weakness for sweet potato fries and binge marathons of Real Housewives", and it always helps to treat the person as a whole being who is much more than their disease or health condition.

As in all relationships, timing matters too. A recent diagnosis or hospitalization can be a catalyst for change, one that erodes common resistance to change.  In the case of Mrs. Hughes, a disease manager or health coach is more likely to find her ready for change in the days following an unplanned trip to the Emergency Room.

If I could choose just one skill to impart to all those working to engage consumers in their health, unequivocally it would be Motivational Interviewing. MI is a "directive, client-centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence." It focuses on uncovering the patient's intrinsic motivations and aspirations, such as being able to walk their daughter down the aisle, play hide-and-seek with their grandson or avoid another trip to the Emergency Room, to push for small steps of progress that move toward a greater, desired behavior change.

The techniques of MI center on asking patients open-ended questions, providing affirmations of any indication of change, reflecting on patient statements, and summarizing what the patient has said. It may sound simple in theory, but it is a skill that takes practice with patients to master. 

In the words of Dr. Allan Zuckoff of the University of Pittsburgh, author of the book, Finding Your Way to Change: How the Power of Motivational Interviewing Can Reveal What You Want and Help You Get There, "The big shift in the practice of MI for most practitioners is that you go from telling patients why they should change or how they could change to drawing out from the patient their own ideas about why change would be beneficial to them and about how they might be able to do it."

When case managers, health coaches and even physicians do master MI techniques, the results are demonstrable. Patients of providers using MI are more likely to use "change talk" in conversations and experience a statistically significant amount of positive outcomes across many measures important to achieving benchmarks. They also are more satisfied patients.

I suspect that many of you who reading my words wish that there was a scientific approach to successful consumer engagement, a precise formula that works every time. If only. Instead, I have found that effective consumer engagement very much is an art – one that depends on a comprehensive view of the consumer created by today's analytics and insights platforms coupled with people skills and relationship management techniques.

Effectively engaging Mrs. Hughes and other healthcare consumers like her is the heart and art of meaningful population health management.