High-risk populations often have complicated chronic diseases and behavioral health conditions, and social issues such as employment, food insecurity, lack of transportation and education can have a negative impact on health. What can the healthcare industry do to get to the root causes of these issues?

Delivering effective care to high-risk populations is challenging. At-risk patients suffer from a combination of chronic diseases, complicated behavioral health issues and adverse social conditions. Not only do they personally battle these health challenges, but their overlapping conditions also strain the entire healthcare system, requiring treatment from many different providers and a large investment of time and resources. If patients are unemployed, uninsured or uneducated, the impact of their conditions is magnified. Combined, these forces result in an epidemic of poor health in our disadvantaged communities.

A stretched healthcare system cannot deliver the highest quality care, and in some areas it may struggle to adequately serve the people who need it most. The effects of this are seen in health statistics from cities across the nation—for example, in 15 zip codes in North Philadelphia, the life expectancy of children is 20 years shorter compared to their counterparts in wealthier zip codes.

Though underlying health conditions are significant factors for these vulnerable populations, many other factors contribute to these statistics. Complex and overlapping economic, physical environment, and social issues such as alcohol and drug use, income and job insecurity, housing conditions, transportation challenges, and much more—known collectively as social determinants of health (SDOH)—can interfere with treatment plans and create a substantial negative effect on health.

It’s important to understand that the healthcare system does not operate in isolation. A doctor may prescribe the highest quality, evidence-based medicine available, but after patients are treated, they leave the medical facility and go back out into an environment that may prevent them from fulfilling their treatment plan. The specific challenges may include everything from a lack of access to healthy foods, to the inability to take time off work for appointments, to pill rationing because an individual can’t pay for a prescription or get a refill  from the pharmacy But the bottom line is that if we don’t understand and address what members and patients are facing in their daily lives, they won’t get the most out of their healthcare.

Another hurdle is that the accessibility of healthcare and the cultures of these populations sometimes work against the system. For example, the emergency department (ED) is the most expensive form of healthcare—but is also the one place where service will not be denied if you don’t have the right kind of insurance or aren’t on the current roster of patients. If a population tends to go to the ED no matter what the issue is, the cost will always be excessive, driving up the cost of treatment and taking resources that could be used to do other valuable work. So, to solve systemic healthcare issues, we have to not only treat, but also change the culture by impacting lives and how populations think. That’s where community partnerships come in; engaging with community organizations that can influence behavior and act as agents of the healthcare system may be able to affect the success of healthcare delivery.

With so many people impacted by systemic barriers to wellness, the entire healthcare industry needs to make more of an effort to fix the problem. Many healthcare organizations and social services organizations are trying to do their part through a variety of programs, such as combating childhood obesity through better eating choices and fitness programs in schools. Despite those good intentions, we aren’t seeing results that translate into measurable improvements in health outcomes across the population. Getting to the root causes of these SDOH-related issues will help us turn the tide so that these vulnerable populations are not just receiving healthcare, but also are on a path to recovery and sustained good health.

To solve the challenges, we need to think more broadly, understanding what individuals are facing and what their lives are like so we can treat the whole person rather than simply their medical symptoms. Enlisting patients as partners in care rather than expecting them to adhere to a prescribed path will provide insight into their lives and particular circumstances, only some of which are controllable. Developing relationships with the right partners to address those factors that stand in the way of good outcomes and coordinating among these partners will help ensure that these at-risk members receive the right treatment when they need it to improve their health.

Optimizing healthcare delivery through population health management—in essence, solving the problems of delivering healthcare to these at-risk members and patients—is a first step in trying to eliminate the problem as a whole.

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