By Josh Morgan, PsyD
Population health traditionally has focused on things like hospitalization rates, epidemiological surveillance and aggregate trends across groups of people, regions, etc., rather than just focusing on an individual person. While important perspectives, these data trends can be too narrow, emphasizing only symptoms, problems and pathology.
As healthcare breaks down silos between specialties (particularly traditional physical medicine and behavioral health), health systems are also recognizing that non-health services (e.g., social services, housing, education, child welfare, criminal justice) are also critical to true whole person population health. Our communities need a more complete, accurate picture of need and a clear view of the impact of multi-system services.
Advances in technology, especially advanced analytics, allow us to tap into a wider range of data, including narratives (e.g., progress and case notes, focus group transcripts), to better gain a whole person view and ultimately improve whole person population health.
A More Comprehensive View Of Community Need
To determine community need, integrating data across multiple health and non-health systems provides a better understanding of both the human outcomes (sometimes referred to as quality) as well as the financial outcomes of services and interventions. Too often, healthcare focuses on both in a narrow, symptom-reduction, healthcare system-only view. But now we recognize that housing impacts hospitalizations; the criminal justice system is often the first line response to behavioral health crises; and education and the job market can be reflective of both problems as well as strengths and resilience.
Advances in technology allow us to integrate diverse and disparate data, match people across data sets and gain insights into cross-system trends that can reshape population health into a more whole person approach. Further, by applying advanced analytics like machine learning, artificial intelligence and even natural language processing to data and to narrative documentation, we can tailor risk stratification of our communities. This can help identify those in need of outreach, engagement and activation services, while also recognizing and empowering more upstream or preventive care interventions and resilience-building.
A more complete, accurate picture of community need across systems also reveals barriers to care. Such insights help us advocate for quality improvement to our systems, as well as build compassion and empathy from providers and staff to people who might otherwise be disregarded as resistant or non-compliant to treatment.
Focusing On The Positive Impacts Of Services
By looking at a more comprehensive picture of outcomes, we can see how our various human services work and systems intersect with each other. As a psychologist, I was frustrated by all the things I wasn’t allowed to do in care (at least officially) because it wasn’t a covered benefit or included in policy or it fell outside of mandated reporting. Usually, these were preventive, strength-building interventions that improve outcomes as well as satisfaction with care.
When we only measure short-term symptoms, like reductions in suicides and hospitalizations, we miss out on the good, whole person work being done. Further, we may unintentionally contribute to stigma and discrimination by only reporting and talking about the negative outcomes associated with some health conditions.
Modern technology gives us a chance to gain a more complete, accurate picture of community need and the impact of services by enhancing a whole person view. How might our policies, benefits packages, social services and healthcare interventions potentially change by seeing connections between our systems? How might we be able to positively impact people’s lives even further by improving these systems and focusing on strengths? In this way, technology empowers the human in population health.
About The Author
Josh Morgan, PsyD, is National Director of Behavioral Health and Whole Person Care at SAS, where he helps health and human service agencies use data and analytics to support person-centered approaches for better health outcomes. He is a #data4good evangelist and advocate for improving benefits, access to care and more holistic services. Find him on Twitter, @DrJosh.