Understanding the Social, Physical and Behavioral Determinants of Health in the Identification, Stratification, and Analytics of Population Health Management

Although there is increasing uncertainty about the future of the Affordable Care Act and the evolution of health reform, the commitment to improved population health outcomes will prevail regardless of any changes or amendments. With continually escalating costs for health services and the challenges of managing chronic conditions among large populations, quality and cost improvement initiatives will always prevail. A sustained focus on the fundamental aspects of the social, physical, and behavioral determinants of health supports the integration of services and the coordination of care.

A key factor for improving health services is the ability of payers and large health systems to accurately identify those individuals who are at risk of poor outcomes. The ongoing use of data and analytic tools supports the identification, stratification and care planning for improving the health of individuals and populations. However, to date, systems that use available claims and other data sources for predicting and managing health outcomes have had limited success in fully integrating the full complement of the determinants of health.

Too often the costs of care are used as the principal driver of health analytics. This approach utilizes upstream financial experience as the driver of downstream care management activity. It mirrors the historical approach of most health services as reactive in the treatment of illness, rather than the promotion of wellness and well-being.

When considering how to better identify at-risk candidates for health improvement and care coordination it is necessary to first understand the complex interactions between the physical and behavioral determinants of health and well-being. Take for example the relationship between depression and heart disease. Recent studies have demonstrated that depression can have as great an effect on the development of heart disease in men as high blood pressure, high cholesterol, smoking, and obesity. And, studies have also demonstrated that men who have already had a heart attack and become depressed are significantly more likely to die from another heart attack than those who are not depressed. Health care data and analytic tools are often focused on high cost episodes of illness and fail to recognize some of the most fundamental and strategic opportunities for the coordination of care and improvement of health outcomes.

InfoMC has developed health care data and analytic tools that are designed to provide actionable information that support the coordination of care across the full continuum of health services. The InSpotlight tools accommodate large data sets of medical and behavioral health claims, pharmacy and lab data, service utilization, and other key indicators of population health.  A common challenge with health analytic tools are their inability to integrate physical and behavioral health indicators at a sufficiently granular level to guide care coordination and management.  InSpotlight integrates the full spectrum of physical, behavioral and social determinants, and targets select populations for improved health management and outcomes.  This is accomplished through the identification of key elements of the covered population; stratification of the population through a rules based approach to determine both high-risk and those most likely to benefit from care coordination and management; and custom analytics to support the unique needs of different populations and provider systems. These tools and resources help establish the necessary care coordination and care management strategic workflows to support effective care and quality outcomes for at-risk and chronically ill individuals.

In order to improve the health of large populations it is first necessary to recognize the intricate and complex interactions among the social, physical, and behavioral determinants of health and well-being. This is accomplished through the development of tools and resources that can assemble large data sets and filter them for actionable and strategic work flows that support both the integration of physical and behavioral health, and the overall coordination of care. Improving the health of large populations and controlling escalating costs of care will always prevail regardless of the twists and turns of current health reform initiatives.