At-Risk Populations—Understanding Who We Serve

Delivering effective care to high-risk populations is challenging. As the costliest patients to treat, at-risk patients—typically those with some combination of tough chronic diseases, complicated behavioral health issues, and adverse social conditions—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. These forces result in an epidemic of poor health in our disadvantaged communities.

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

While underlying health conditions are significant factors for these vulnerable patients, there are many other things that contribute to these statistics. Complex and overlapping social, economic, physical environment, and societal issues such as alcohol and drug use, income and job security, housing conditions, transportation challenges, and much more can interfere with treatment plans and create a significant negative effect on health.

With so many people impacted by these systemic barriers to wellness, we need to make more of an effort to fix the problem. Many organizations are trying to do their part through a variety of programs, such as combatting childhood obesity through better eating choices and fitness programs in schools—but despite the good intentions we aren’t seeing enough results that translate into measurable or significant improvement of health outcomes across the population. Getting to the root causes of these issues will help us turn the tide so that these vulnerable populations are not just receiving healthcare, but are on a path to deal with their issues so that they can recover and remain healthy.

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 people 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 vary, including everything from a lack of access to healthy foods, to the inability to take time off work for appointments, to pill rationing because a patient can’t pay for a prescription or get to the pharmacy for a refill. But the bottom line is that if we don’t understand and address what our 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 even 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 healthcare, we have to not only treat, but change the culture by impacting lives and how populations think. That’s where community partnerships come in—engaging with community organizations who can influence behavior and act as agents of the healthcare system may be able to affect the success of healthcare delivery.

To solve healthcare, we need to think more broadly, understanding what patients are facing and what their lives are like so we can treat the whole person rather than just their medical symptoms. Enlisting patients as partners in care rather than expecting them to adhere to a prescribed path will provide insight into the people and their 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 patients receive the right treatment at the right time to improve their health.

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


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