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As hospitals and health systems continue to grapple with COVID-19, population health should be part of every organization’s strategy. Having been on the provider and payer side of healthcare for more than 20 years, I’m bullish on the move to whole person care. Today’s technology has made it easier to gather a variety of data about a patient, giving a more wholesome view of who they are and the hurdles they face. At Hackensack Meridian Health(HMH)our population health strategy is focused on providing patients the right care, at the right time, and in the right place. If we execute that approach successfully, we ultimately improve our patient’s quality of care while lowering medical costs.

Reenvisioning the referral

For years, referrals have been a way to provide a patient the next level of clinical care. What if we looked at referrals through a broader lens and saw referrals as a way to address a patient’s other needs like housing or food insecurity. These social determinants of health affect a person’s overall wellbeing and could prevent them from achieving their optimal health. This is why HMH began a community health program to tackle social determinants of health and drive whole-person care.

Part of our social determinants of health program includes creating new kind of referral platform. A platform that connects patients with resources in the community that can help them find a path to better health. Tomorrow’s patient may leave with a referral for a cardiologist along with a referral to the local food bank or a free mental health counselor. Our ability to connect patients with these valuable resources helps us address the whole patient and become a true health champion.

Using technology to enable your population health strategy

Data is only useful if you make it credible and actionable. Like many other hospitals and systems, we have numerous data feeds and tools across our system, and we must ensure that the information can drive better care. Our work with Cerner and Lumeris, through their Maestro™ collaboration, is helping us do just that. We integrate EHR (including data from Epic and others), claims, lab, pharmacy and other relevant data from soon to be more than 100 clinical data sources, into our central data warehouse in Cerner’s HealtheIntent℠ for aggregation and normalization. Then we push predictive analytics and actionable insights from Lumeris into our Epic EHR platform where it’s easily accessed by our care team. The care team leverages this data, with the support of Lumeris, to identify patients with rising risk and open care gaps in need of the right interventions.

Clinical transparency

Once you have actionable data, you need to share these insights with your clinicians. Empowering your providers is essential so they can deliver the highest quality care while managing medical costs. Our clinically integrated network, Hackensack Meridian Health Partners, is our organized physician network with approximately 4,600 participating physicians serving more than 371,000 at-risk lives. In partnership with Lumeriswe created physician scorecards to communicate performance transparently and encourage best practice sharing.

With this holistic approach to value-based care—a progressive risk contracting strategy, focused clinical transformation, patient engaged shared decision making, and the right technology infrastructure and operating model—we can capture the full picture of our patients and take action across the entire population.