Resources to help hospitals and physicians navigate post-pandemic care.

Healthcare recovery: Social determinants and population health

July 29, 2020
Resources to help hospitals and physicians navigate post-pandemic care.
President and CEO

As Geneia blog readers already know, I am a big fan of David B. Nash, MD, MBA. Arguably he is one of the nation’s primary thought leaders within the population health movement. His professional accomplishments are numerous:

  • Board-certified internist who is internationally recognized for his work in public accountability for outcomes, physician leadership development and quality-of-care improvement
  • Founding dean emeritus of the Jefferson College of Population Health
  • One of Modern Healthcare’s Most Powerful Persons in Healthcare
  • Author of more than 100 articles in major peer-reviewed journals and editor of 23 books

He cares deeply – about public accountability for outcomes, physician leadership development, quality of care improvement, and more recently about how patients, physicians and the healthcare system recover from the first surge of COVID-19. He’s the kind of person who encourages others to care as deeply as he does. In fact, it was a Zoom meeting I had with Dr. Nash in April that led Geneia to create a series of resources for physicians, hospitals and payers navigating post-pandemic care:

So when Dr. Nash asked if I would join his panel, The Role of Population Health and Social Determinants of Health in Health System Recovery, at the Virtual Summit on Health System Recovery from the COVID-19 Pandemic, I gladly said yes. So did:

  • Dave A. Chokshi, MD, MSc, FACP, clinical associate professor, NYU School of Medicine; former vice president and chief population health officer, NYC Health + Hospitals
  • Luis Lasalvia, MD, MBA, vice president and global medical officer, Siemens

We had lively and informative conversation. Among my favorite Dr. Nash quotes were,

  • "No outcome. No income."
  • "We know from Geneia research that giving clinicians the tools to tackle social determinants can reduce physician burnout."
  • "I want to thank clinicians at the bedside of COVID-19 patients for their amazing valor."

Dr. Chokshi offered lessons learned on the frontlines of COVID-19 care. His hospital, NYC Health + Hospitals, is New York City’s public health hospital so he experienced firsthand the disproportionate impact COVID-19 has had on people of color.

In the words of Dr. Chokshi, "As we were all masking up, so much was being unmasked in terms of the inequities low income and people of color face." He largely attributed the outsized impact to unmet social determinants of health (SDoH).

When asked what SDoH data he wants for the next surge of COVID-19, Dr. Chokshi discussed the need to knit together what’s happening at the individual patient level with population-level data:

"We need to contextualize population data with the individual factors that can lead to adverse outcomes."

Dr. Lasalvia of Siemens was asked how to engage clinicians in social determinants. His response:

  • Start now.
  • Educate providers about the impact of SDoH on patient outcomes, which research suggests drive more than 80 percent of outcomes.
  • Create economic incentives.
  • Stratify priority patient populations for care management.

Geneia tweet June 25, 2020

I discussed Geneia’s long-time work on social determinants of health, and the importance of leveraging this kind of data so care managers can work with patients to resolve barriers to care – work that’s vital as patients and health systems try to recover from the first surge of COVID-19. With more than 60 percent of people saying they have been adversely impacted by social determinants during the pandemic and they will wait one to six months to seek routine care due to fear about contracting COVID-19, we know health system efforts to restart regular healthcare are, and will continue to be, quite challenging.

Geneia’s work with hospitals and physicians suggests a digital front door strategy that lets patients know they are truly known and cared for is essential. An example I’ve often shared is Lucy*, a diabetic concerned about COVID-19. I hope you’ll read the more detailed version in the blog, Telehealth and the Digital Front Door Are Connected, but in short, Lucy is concerned she has been exposed to COVID-19.

Lucy: An example of the digital front door in action

Lucy calls her primary care physician’s office for guidance about whether to get tested. Jess, a patient intake specialist, answers her call, and immediately accesses her patient record. Jess can readily see Lucy has diabetes, which puts her at higher risk for COVID-19 impacts. Jess asks Lucy a series of questions that are embedded in the care management platform the physician practice uses. Her symptoms, diabetes diagnosis and her possible exposure from her son cause Jess to refer Lucy to the nurse care manager for clinical assessment.

The nurse care manager uses the clinical questions embedded in the care management platform to assess Lucy’s level of exposure to the virus, and ultimately refers her for testing. As a follow up, she emails Lucy educational information, What to Do If You’re Sick with COVID-19, and testing information. Lucy’s clinical assessment and the email with follow-up information are saved within the care management platform.

Her doctor’s use of a care management platform is a key component in the practice’s digital front door strategy. For Lucy, this means her doctor’s office immediately understood she was at higher risk of COVID-19 impacts due to her diabetic condition, and given her symptoms, was able to quickly route her to testing.

To view our conversation, visit

*Lucy is fictional and not intended to represent any specific person. This information is provided for illustrative purposes only.