Population Health and Social determinants of health.

Sounds super sexy right?

I just finished a recorded session for NAHC annual conference that will be aired October 20th – click here to sign up for the virtual conference: http://2020annual.nahc.org/

The session was:

“Private Duty – Positioning as a Key Partner in Effective Population Health Management”

I was a part of it with Cindy Campbell – HMA Healthcare Informatics, BSN, RN, COQS, Director Operational Consulting WellSky Advisory and Outsources Services (formerly Fazzi Associates) and Dr. Lucy Andrews, DNP, MS, RN Founder, and CEO: At Your Service Home Care, Chair CAHSAH.

It was an excellent presentation, and I would like to share some of the “AhHa” moments with you!

Cindy set the stage and slapped us in the face with this slide – it was a sit up and pay attention moment. As an OT, of course, I know about functional limitations, but holy moly – $740 billion per year by 2025! Cindy got us off to a great start!

Our hypothesis is that home care generates substantial cost savings for complex chronic patients with functional limitations and supports a compelling business case for home care value in population health management.

Lucy went onto discuss the three strategies from The American Healthcare Association.

  1. Screening and information: Providers systematically screen patients for health-related social needs and discuss the impact these challenges may have on their health with them
  2. Navigation: Providers offer navigation services to assist patients in accessing community services
  3. Alignment: Providers partner with community stakeholders to more closely align local services with the needs of local patients

Cindy shared an example of a Heart Failure Program.

  • Provide a combination of ADL/IADL support as needed, include transportation, medication reminders, and RPM with LVN/RN call center support as State license permits and condition warrants.
  • Measure and use data wanted by your hospital or payor partner
    • They want READMISSIONS LOWER for high recidivism, high cost, ‘FREQUENT FLYERS’ for example:
    • YOUR POPULATION OUTCOME = achieved fewer readmissions, e.g., 5% reduction in 30-day rehospitalization in CHF patients
  • Track and manage interventions to prevent rehospitalizations
  • Share your successful decrease in readmit to hospital with specific patient populations.
  • Consider the integration of innovative RPM, virtual visit, and connectivity platforms within your programmatic offerings.

My portion of the course was about business development.

I shared the steps to take to gain more referrals through population health programs.

I also shared case studies of current and past clients:

  • Nurse owned HH and PD in which the hospital referred and paid 4 hrs a day for 30 days for high-risk readmission patients.
  • Nurse owned HH and PD is exploring a hospital to home program and is in step 4 out of 7 in the Home Care Sales Exploration Model.
  • An In-Home Care provider who aggressively pursued the Medicare Advantage opportunity for personal care and transfers

I am so grateful to be in the company of colleagues – Lucy and Cindy – who are at the top of their games sharing their insights!  We get the chance to take a peek at how other agencies are working.

That is the benefit of working in partnership, having a great network, seeing what is working for others, asking great questions, and sharing information/ solutions.

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It’s a great way to connect with some of the industry’s leading experts on recruiting, retention, pop health, protecting your brain health, and many other topics we bring to the group to enhance your wealth and your health!

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Impact more lives!


P.S.  Do you have educational sales materials that present your agency as the solution for CHF, COPD, or Alz by managing the disease process at home?  We do – jump on a call with Mike (click here for his calendar) to tour you around our sales education pieces for referrals sources – so that you can get the high-value referrals which will allow you to blow out your goals!