“And this mess is so big and so deep and so tall, we cannot pick it up. There is no way at all!” Dr. Seuss
Theodor Geisel authored “The Cat in the Hat” in 1956 under the pen name Dr. Seuss. In the story, the Cat and his companions must clean up the shambles they have made of the children’s house. The Cat laments, “And this mess is so big and so deep and so tall, we cannot pick it up. There is no way at all.”
For more than four months we have anguished over the coronavirus outbreak and its roiling toll on humanity, including our patients and our healthcare workforce. We feel the heavy weight and worry of a public health “mess” that seems almost insurmountable. Furthermore, public health disasters like COVID-19 disproportionately impact marginalized and minority populations.
While serving as Director of Infectious Diseases and Director Population Health at the Boston Public Health Commission, I witnessed this same situation with the Hepatitis A Virus outbreak in Boston. There was disparate impact on vulnerable populations. Heightening the public health impact, underserved persons often have multiple underlying medical conditions coupled with financial instability and food insecurity.
For example, the lack of an economic cushion impairs ones’ ability to prepare and limits options, such as sheltering outside of a hot zone or working remotely in the case of COVID-19. Inequality is magnified further by disparities during the recovery process.
One way to begin to address some of these concerns during the current crisis is to combine all available social determinants of health (SDOH) data with demographic, clinical, pharmacy and claims data to track infection rates, treatment response, and outcomes to identify and address gaps in care. Although not perfect, the time is now to use whatever technology is currently available and work collaboratively to improve our public health outcomes.
Impacts on Public Health
In the midst of this pandemic, unparalleled in breadth and severity, our most vulnerable populations lack the resources, support, and often opportunity to prepare for and respond to emergencies. Unlike any disaster in recent years, this outbreak has impacted global economy and personal well-being. Many individuals have lost their jobs or work in jobs which increase their risk of exposure. The impact of prolonged social isolation has led to depression, anxiety, worsening pain and chronic medical conditions for many. However, the risk is greatest felt among the most vulnerable. Here are three specific examples.
- Social distancing is a crisis within the crisis for the elderly, informed and impoverished.
- Many lack the ability to obtain food, medications and other essentials amid local shortages and limited public transportation.
- Internet access or credit cards for essential purchases are often nonexistent.
We see nationwide and in real-time the unintended consequences of social distancing, lack of access to healthcare and delays in seeking care due to risk of exposure or infection. There are increases in suicide, domestic violence, child abuse, substance use disorders, unmanaged depression and anxiety, and deaths in the home prior to EMT arrivals. Big cities are hardest hit, but the personal pain is equally well distributed.
The lack of clear, consistent, trusted communication prolongs and exacerbates anxiety. What should our action plans look like now?
Enter SDOH Action Plans
As healthcare technology innovators we can assist frontline clinicians by enabling them with insights from SDOH analyses derived from data aggregation and integration from numerous different sources. Risk-stratification to identify persons at highest risk should be performed using artificial intelligence and machine learning (AI/ML). By doing so, public health agencies will derive actionable intelligence to truly improve health and well-being.
- Harness data from all available sources regardless of format or system including EMRs, claims, HIEs, pharmacy, labs, and community organizations.
- Perform data analysis to find actionable insights.
- Use information gleaned to identify high risk patients, proactively identify need and provide care management supporting the entire person.
- Expand care coordination programs to take advantage of built-in patient assessments for SDOH, chronic and complex care management, depression/anxiety, cognitive function and fall risk among many others.
Eight Practical Steps to Take Now
Persons at greatest risk of severe COVID-19 infection include individuals over 65 years of age, especially those over 80, and persons with comorbidities. Diabetes, hypertension and other cardiovascular diseases, end stage renal disease, liver disease, asthma, COPD, smoking, obesity, and documented depression are the most important comorbidities to identify. Here are eight practical steps to take now to better monitor and manage the current public health crisis.
- Look for “opportunity density” by targeting ZIP codes where underserved populations reside. If possible, geo-map your at-risk populations.
- Develop a prospective risk score using and combining multiple risk-assessment tools such as The Johns Hopkins RST, the CMS HCC, and C3 Score for cancer comorbidity.
- Include additional factors and metrics in risk scoring such as age, frailty, and history of emergency department and hospital stays over the previous year. Also note individuals who are physically impaired or disabled, along with newborns and their mothers.
- Use available machine learning and artificial intelligence capabilities to incorporate beneficiary data into your data warehouse. Take data in any format, from any system and source. Cleanse, normalize, and then aggregate and integrate. Finally apply quality and business rules engines, AI/ML and predictive modeling. Stratify and prioritize the top 10% within the overall risk group. For instance, if in your ACO or other risk contracts you help take care of a population of 90,000 beneficiaries, find the 9,000 most at-risk patients, and then further stratify that 10% into another top 10% therein for immediate action.
- Focus on patients’ immediate medical and social needs focused on need and access to medications, food, stable housing and transportation.
- Seek and recognize patient preferences for outreach, care coordination and virtual visits. While a telehealth encounter is a good alternative to an office visit for many patients, start with a simple telephone appointment if your patient is otherwise reluctant.
- Build serial, team-based care touchpoints deploying doctors, case managers, nurses and social workers. Expanding access to all primary care practices, including pediatrics, will be critical.
- Continue with your value-based care strategy, using telehealth capabilities to conduct annual wellness visits, transitional care management and chronic care management with remote patient monitoring.
The COVID-19 pandemic highlights pervasive and systemic healthcare disparities and shines necessary and overdue focus on the social determinants of health. Data analytics and advances in population health technology including AI/ML provide us the unprecedented opportunity to identify and reach those individuals at greatest risk and for whom we have an obligation to perform our very best.
Now on Demand
From The Tate Chronicles, host Jim Tate talks to Jenifer Leaf Jaeger, MD, MPH, the Sr. Medical Director for HealthEC. Dr. Jaeger is an Infectious Disease Pediatrician and Pediatric Urgent Care specialist. She received her medical degree from Washington University, St. Louis, and MPH from the Harvard T. H. Chan School of Public Health. Currently Senior Medical Director at HealthEC in New Jersey, she previously served as Director, Infectious Disease Bureau and Population Health for the Boston Public Health Commission. She discusses the intersection of population health and public health in a pandemic.