Patrick Young, the president of population health at Hackensack Meridian Health, sums up his team’s focus this way:
“A physician may give a prescription to someone for something that needs to be refrigerated, but they may not ask: Do you have a refrigerator?” he said. “The doctor may just assume that they do. And then, that person shows up back in the emergency room because they couldn’t take their prescription because they didn’t have a refrigerator — so, they never got it.”
Health systems, Young said, need to start taking a different approach to care.
“We tend to treat clinical issues,” he said. “If a person has a medical issue, we treat that issue. But the reality is, care doesn’t stop when the person leaves the hospital or the physician practice. What we really need to do is start thinking a much more holistic view of the patient.
“We believe that, if you combine the great attributes that HMH has brought from a clinical perspective, and then start to address the issues of social determinants — such as food insecurity issues, housing, access to care, mental health support — we can not only improve someone’s health, but their quality of life.
“We believe there are synergies by bringing those two areas together. And we’ve invested a significant amount of resources and money to make that a reality at HMH.”
Young, who came to HMH in 2016, has been working on this issue for years — and he knows it will take years before its impact will be felt throughout the state. But HMH — and others — have made giant steps, even during the pandemic, he said.
Young recently talked with ROI-NJ about the challenges and opportunities around population health.
ROI-NJ: Let’s start with the pandemic, the biggest health event of anyone’s lifetime. The pandemic showed the health inequities we have like nothing ever has before. How has that impacted your work?
Patrick Young: The pandemic has brought some of the real issues in underserved populations to the forefront. They’ve always been there; they are just more visible. Access to food is a simple example. Or access to transportation.
We really didn’t have a strategy to address these issues before. And, now, we do.
ROI: How does HMH identify all the social determinants of health that are impacting people?
PY: For HMH as an organization, we are embedding social determinants of health as a part of what we do in relation to clinical care. We have embedded a module that asks questions when the person interfaces with our physicians or our nurses or our social workers — and that information becomes a part of that individual’s permanent file. And then, based on the responses, it actually classifies what is the highest social determinant issue, whether it’s food, transportation, housing, access to care or mental health treatment, whatever it may be.
We then have a significant number of care coordinators who manage the clinical aspects of a patient when they leave a facility, such as follow-up appointments. We also have a community health worker who works alongside the care coordinator to help.
If the care coordinator calls the patient about a follow-up appointment and the person says, ‘I’d like to go, but I don’t have a way to get there,’ the community health worker can work on getting them transportation to go to the doctor.
ROI: This is a tall order. As the pandemic has shown, there is a certain level of distrust of the health care officials in some communities. Talk about that challenge?
PY: The community health worker is someone who actually lives in the community, so they already understand the challenges people face. That’s important. You don’t want to call someone and ask them where their local food store is — there might not be a local food store. The community health worker already knows the food store is in the next town over, so, they’re working with them on getting transportation there.
ROI: It sounds as if there are a lot of people involved?
PY: There are, but people want to help. When you go out and talk to community-based resources, their biggest frustration is that people don’t know that they’re even there — or don’t know how to access them. So, we’ve created a systemwide network where we can access community-based resources, we can refer individuals there, we can make sure that clinicians can see the information.
It’s all about reaching individuals where they are, because individuals can’t necessarily always go to see a doctor or can’t always go to a clinic. And, so, how do we reach out to those individuals in need?
We really don’t want to have a person’s ZIP code define the quality of their life and the quality of their health. And that’s really what we’re trying to change here with our community health workers working alongside our care coordinators. We’re really working together to optimize that person’s quality of ife.
ROI: Talk about some other partners?
PY: We’re working with Bergen County — and we’ll be doing this with other counties. We’re listing all of the services that they provide, so we have a database of community-based resources that we can refer to. We’re working with a company called NowPow to create an automated system, so a social worker doesn’t have a gigantic binder on their desk. It’s a great access point for us.
And there’s Horizon (Blue Cross Blue Shield of New Jersey)’s Neighbors in Health, where we are actively engaging 1,200 individuals that we’ve identified with Horizon, helping them address their issues.
We’ve had some conversations with (RWJBarnabas Health) about the geographies where we overlap: How can we work together to optimize the communities that we serve?
This has become a much broader, much more community-based initiative. We believe, by bringing organizations such as Horizon and RWJBH and us together, we can really make a difference in the communities that we serve.
ROI: And, while population health can impact all of the communities you serve, finding the right communities makes the biggest impact, correct?
PY: It’s really about understanding your total population — and then understanding there’s a subset of that population that you can use statistics, predictive modeling and data that we have to say, ‘Here are the individuals who are most at risk — and we need to work with them not only from a clinical perspective, but also from a social issue.’
Combining those two datasets together to optimize the quality of that person’s life. And, in a lot of cases, it’s not just about addressing one individual’s issue; sometimes, you’re addressing the entire family. If there is a food insecurity issue, it’s an entire family issue.
ROI: Which takes us back to the top: This is not about treating a clinical issue, but a whole person, family and community. That’s a big challenge.
PY: This a completely different approach to care that I don’t think we’ve ever seen anywhere else in the country. But this is something we truly believe in. (CEO) Bob Garrett and our board of directors have made this one of our top strategies for 2021 and have committed resources.
For us, it’s a three-year strategy, because we know that it’s going to take a long time to really implement this program. It’s not a sprint, it’s a marathon. And we’re in it for the long haul, because we really do believe that we will make a difference in people’s lives.
It fulfills our mission as a health care organization. You can’t get any more mission-driven than this.