Population Health: Staying Focused through the Pandemic and Beyond

Although the United States has the world's best “sick care” system for patients requiring complex care, its ability to preserve and enhance health across populations remains nascent. What is required is a fundamental reframing of focus, away from reactive-treating illness to proactive-providing longitudinal evidence-based care that enables health and wellness. Our responsibility as clinicians is to facilitate that shift toward “well care.” Part of that transition requires the health care system to eliminate the current unevenness in how we identify, analyze, and address social drivers of health, which are an enormous obstacle to achieving uniform and equitable health care quality goals.

The Yale New Haven Health System (YNHHS) serves ∼4 million people across a geography that includes half of the state of Connecticut (CT), plus parts of Rhode Island, Massachusetts, and New York. Connecticut and the Health System's primary geography includes some of the nation's wealthiest zip codes as well as 3 of the poorest (ie, Bridgeport, New London, New Haven). YNHHS has an uncommon identity as a premiere academic health system anchored in its relationship with Yale University that also functions as a safety net hospital in 2 of the state's 3 largest cities. As such, we have a responsibility and mission that requires us to consider and address the broad range of vulnerability among those we serve and create reliable systems that prevent and manage heart disease, hypertension, and diabetes—the most prevalent threats to population health.

Maintaining a Population Health Focus During the Pandemic

Universally, the COVID-19 pandemic delayed preventive screenings, disrupted longitudinal care, and placed unprecedented burdens on health care workers and hospital systems. The trauma experienced by patients and clinical providers, which continues to play out, will have a lasting impact on how care is delivered in the United States. Challenges to population health management required rapid implementation of new approaches. YNHHS deployed several key interventions that required substantial changes in its infrastructure.

The first intervention was a system-wide shift to telehealth as a core component of care delivery. The majority of outpatient visits were converted to telehealth visits, necessitating changes in reimbursement and technology models. The changes were organized as a unified structure across the Yale School of Medicine and YNHHS (Fig. 1).

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FIG. 1.

Population health management infrastructure: Yale School of Medicine and Yale New Haven Health System. ED, Emergency Department; ICU, Intensive Care Unit.

The disproportionate impact of the pandemic on our most vulnerable community members became clear very early. As such, the equity lens was embedded early into all parts of our response to COVID-19. As one of the first health systems to roll out COVID-19 testing at scale, we dramatically increased our cadre of community health workers (CHWs) from 2 to 17 to address barriers to health and health care among marginalized groups. These CHWs, who were drawn from our communities and were often multilingual, were initially deployed to ease equitable access to COVID-19 testing, follow-up on patients with COVID-19, facilitate access to personal health records, screen for social drivers of health, and make connections to address identified needs.

Later, the CHWs pivoted to support education and easy access to COVID vaccination and were key to the Health System's ability to demonstrate a remarkably equitable vaccination pattern. Together with experts at Yale University, the Health System built on existing relationships with community organizations to ease access to vaccination in a way that reflected the ground realities of the diverse communities in our geography. In addition, we worked with municipalities to use an innovative “reverse 911 system” for direct outreach to patients living in neighborhoods with high prevalence or risk for serious illness. The Health System's vaccination enterprise ultimately vaccinated a population that perfectly reflected the demography of its geography—a demonstration of equity in vaccination uncommon across the country. These interventions hold promise in treating other illnesses, including diabetes and hypertension.

Lessons and Looking Ahead

Postpandemic, CT is ahead of the curve in terms of a systematic approach to social determinants of health (SDOH) screening. YNHHS has developed a standardized, simple, and integrated SDOH screening model that enables the collection of reliable data, which can be used to identify patients with needs, and then make connections to community resources. Similarly, as part of our development of our Office of Health Equity, we have standardized the collection of race, ethnicity, and language data to understand health outcomes according to these key attributes, which are drivers of inequitable care. The equity lens is embedded into our clinical performance improvement structure, and at Yale School of Medicine and YNHHS, current medical students and postgraduate trainees are being trained to recognize social drivers of health (eg, housing insecurity, poverty, food insecurity, lack of transportation), respond, and follow up to ensure optimal outcomes.

Value-based care—the reformed reimbursement structure that supports the transition to well care—is far more than just a financial model. It necessitates collaboration over competition, and a transition from lone practitioners to team-based care, where frontline clinicians can rely on resources such as care managers, pharmacists, CHWs, and others to support top-of-license work, help calibrate care to individual patient needs, reduce health care worker burnout, and achieve clinical quality goals. YNHHS is intentionally moving forward in this vein—starting with the 38,000 individuals covered by its self-insured employee health plan.

Its employed medical group operates a high performing Affordable Care Organization and participates in a number of value-based arrangements with payers. The Health System is also exploring other creative arrangements that facilitate enhanced quality and reduced health care costs while maintaining a margin for the System that supports a virtuous cycle of reinvestment into the enterprise. Growing the number of patients—so-called attributed lives—in value-based arrangements will enable the achievement of all 3 outcomes: enhanced quality and patient experience, reduced waste, and preservation of a margin.

Finally, enhancing the health of populations requires health systems to support their frontline clinicians in managing the enormous pace of change in the science of medicine, including understanding of disease and a cornucopia of new therapeutic modalities. At Yale New Haven Health, our approach to care convergence is Care Signature, and is an inclusive physician-led initiative that utilizes evidence-based medicine, clinical consensus, and a novel way of rapidly deploying clinical and operational pathways directly into the frontline clinical workflow. Far from an expectation that clinicians rely on inconvenient reference resources, Care Signature allows constantly updated pathways to support clinicians as they work in the electronic health record. We view this unique program as a key differentiator in our efforts to support our clinicians in providing reliably high-quality and equitable care to the patients we are privileged to serve.