Lucas C. Carlson, MD, MPH

The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed how health care systems deliver services and revealed the tenuousness of care delivery based on face-to-face office visits and fee-for-service reimbursement models. Robust population health management, fostered by value-based contract participation, integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises. In this article, we describe how mature population health programs in a learning health system have been rapidly leveraged to address the challenges of the pandemic. Population-level data and care management have facilitated identification of demographic-based disparities and community outreach. Telemedicine and integrated behavioral health have ensured critical primary care and specialty access, and mobile health and postacute interventions have shifted site of care and optimized hospital utilization. Beyond the pandemic, population health can lead as a cornerstone of a resilient health system, better prepared to improve public health and mitigate risk in a value-based paradigm.

Robust population health management integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises.

The coronavirus disease 2019 pandemic revealed the tenuousness of care delivery based on fee-for-service reimbursement models.

Population-level data and care management facilitate identification of demographic-based disparities and community outreach.

Telemedicine and integrated behavioral health have ensured primary care and specialty access, and mobile health and postacute interventions shifted site of care and optimized hospital utilization.

Beyond the pandemic, population health is a cornerstone of a resilient health system and can improve public health while mitigating risk in a value-based paradigm.

Prior to the coronavirus disease 2019 (COVID-19) pandemic, the US health care system was in the midst of major transformation—shifting away from the inefficiencies of fee-for-service toward value and patient-centeredness. The pandemic has highlighted the fragility of a volume-driven health care industry and illustrated how mature population health infrastructure can promote public health, strengthen health system resiliency, and support financial recovery.

Historically, large health care systems focused their population health efforts on optimizing performance in risk-based insurance contracts.

 However, the COVID-19 pandemic has caused priorities to shift rapidly. With a dramatic decrease in procedures and in-person visits, population health stands to become increasingly vital in health care delivery to improve outcomes and reduce costs.

 By utilizing the technology, governance, and infrastructure of existing population health programs, organizations can adapt care delivery to meet emerging patient needs. In this article, we examine how strategic population-based efforts can combat COVID-19, highlighting our experience within Partners Healthcare System (PHS), a large integrated health system based in Massachusetts (summarized in the 

). We detail the programs that have had the highest impact at PHS and other health systems in potentially stemming the impact of COVID-19, and we explore the fundamental role of population health in revitalizing health systems beyond the pandemic.

Population-Level Data: Identifying High-risk Patients and Potential Gaps in Care

During COVID-19, PHS utilized established population health information systems to identify high-risk patients, including data from clinical sources, claims reports, and risk capture efforts. We developed real-time dashboards to merge geography, demographics, and clinical characteristics of patients with COVID-19 to better understand disease incidence, drive service delivery decisions, and identify “hot spots” among vulnerable communities (

). For example, understanding that more than 6000 non–English-speaking patients were tested and 56% tested positive allowed rapid deployment of testing, food delivery, and kits with masks and disinfectant to high-prevalence neighborhoods using interpreter support.

 In addition, dashboards enabled leadership to review a defined set of COVID-19 key performance metrics on a daily basis, driving coordination and communication across a dispersed network.

Other population health programs have similarly adapted existing data and analytics infrastructure to support pandemic response efforts. For example, the University of California San Francisco Office of Population Health and Health Equity created an interactive map curating publicly available community data including COVID-19 cases, deaths, social determinants, and health outcomes.

 As a result, providers, payers, and industry partners could identify and address drivers of poor health outcomes, such as food insecurity. After the pandemic, these dashboards will be able to identify ongoing health inequities and monitor for COVID-19 recurrence (Table).

The COVID-19 pandemic has also had a collateral impact on chronic disease management.

 Existing risk capture efforts were used to identify complex patients at risk for adverse outcomes and to facilitate direct outreach. For example, registries for hypertension, diabetes, and chronic kidney disease identified the highest-risk patients to receive laboratory monitoring or medical procedures, prioritizing those who were likely to need dialysis in the near future.

 Similarly, a registry of patients with frailty, defined by the Johns Hopkins ACG System, was used to identify patients for augmented home-based care and goals of care outreach.

Care Management: Delivering Public Health to High-risk Patients and Addressing Disparities

For the last decade, the integrated care management program (iCMP) has been an essential component of PHS population health to coordinate care, improve outcomes, and reduce cost for high-risk patients by leveraging a dedicated nurse, social worker, or community health worker.

 This team was utilized as a public health workforce to provide outreach to patients at increased risk for adverse outcomes, including elderly patients, frail patients, and those with complex health conditions. They performed wellness checks, provided COVID-19 education, and conducted serious illness conversations clarifying goals of care before patients presented to a hospital.

 During the COVID-19 surge, iCMP reached out to 98% of its 15,000 adult and pediatric patients with an average of 14 contacts per patient and called more than 5000 non-iCMP patients at high risk for COVID-19.

The PHS ED Navigator program, which serves as an emergency department (ED) resource to link patients to primary care and social services, adapted its work to be telephonic and to identify isolation resources for patients who are homeless, housing insecure, or living in crowded conditions. ED navigators increased their work from 400 to 528 encounters monthly across the network to connect high-risk patients with critical resources.

Population health teams from other organizations, such as the Public Health Institute (PHI), have similarly adapted operations to meet public health needs exacerbated by the pandemic.

 PHI created guides about telephonic asthma management, provided opioid use support, and addressed health-related social inequities as part of its remote care management. Such care management programs will be critical after the pandemic to follow patients affected by COVID-19 and to identify those at risk of poor outcomes due to deferred care (Table). By proactively addressing chronic health conditions and the social determinants underlying them, care management can stem the impacts of a future pandemic.

Home Hospital and Postacute Collaborative: Providing Flexibility When Site of Care Matters Most

PHS site of care and postacute programs have been rapidly scaled to offer remote care options for patients with COVID-19. The Home Hospital program provides inpatient level of care to low-acuity patients in their homes, and the Mobile Integrated Health (MIH) program uses paramedics to further support home-based care delivery.

 During the pandemic, these programs expanded capacity to prevent potential COVID-19 exposure in patients requiring hospital care and to monitor patients with COVID-19 who were recovering at home, reducing inpatient utilization and preserving higher-acuity resources.

 Within the first 46 days of MIH expansion, teams evaluated 102 patients with confirmed or suspected COVID-19, with 92.2% of patients able to continue care at home. During April to June 2020, 96 additional patients without COVID-19 symptoms were admitted to Home Hospital for an average of 4.8 days, resulting in approximately 480 inpatient bed days saved.

Postacute care is critical to identify safe locations for patients with and without COVID-19 to recover and to maintain inpatient hospital capacity.

 PHS mobilized an existing collaborative of long-term acute care hospitals and skilled nursing facilities (SNFs) to address the surge in postacute capacity by creating unified admission plans, creating COVID-19–specific SNFs, and supporting personal protective equipment (PPE) provision to facilities.

 This team’s expertise was extended to support the creation of a 1000-bed field facility called Boston Hope Medical Center, with a dual focus on respite care for homeless populations and postacute care for those recovering from COVID-19.

The University of Washington also collaborated with postacute partners to develop a comprehensive strategy for COVID-19, which included establishing clear criteria for facility admission, providing PPE training, equipping testing supplies, and developing isolation plans.

 Population-based postacute strategies during the pandemic helped prevent delays in discharge, spread of infection, and overwhelmed facilities to mitigate the effects of the public health crisis.

Behavioral Health: Providing Psychological Support at a Time of Great Need

COVID-19 has brought numerous mental health challenges due to elevated stress, financial insecurity, and exposure to traumatic events.

 To address these needs, we adapted existing programs in behavioral health management, substance use disorders, and digital health. We identified patients at high risk of mental health complications and used primary care–based resources to intervene on acute anxiety and stress. We also adapted substance use disorder programs to include virtual recovery coaching, resulting in 10 virtual recovery groups weekly, and supported medication-assisted treatment when new regulations allowed prescribing without an initial face-to-face visit.

Across Massachusetts, organizations leveraged the rapid reforms in insurance and Health Insurance Portability and Accountability Act waivers to increase access to telehealth psychiatric care and to enhance support for residential and group home settings.

 At PHS, digital health pilots expanded capacity for internet-based cognitive behavioral therapy (iCBT) and mindfulness tools and to offer a Spanish-language iCBT platform. PHS also increased access to telehealth programs and psychiatric care for employees and their families. In the first 3 months of the COVID-19 pandemic, 148 patients and employees were provided iCBT.

In New York, the New York City branch of the National Alliance on Mental Illness embraced population-level telephonic mental health services and expanded digital platforms for anxiety, depression, and peer support, particularly for New York City health care workers.

 Behavioral health programs developed during COVID-19 will be increasingly needed to “flatten the behavioral health curve” of subsequent trauma, grief, and unhealthy coping, and they will be vital in the future to offer more flexible and rapid access to mental health resources (Table).

Telemedicine: Ensuring Access While Maintaining Social Distancing

Early in COVID-19, CMS eased telemedicine regulations to promote telehealth services and enable social distancing.

 This rapid shift facilitated the development and scaling of telehealth in essential ambulatory care and new COVID-19 programs.

 Nationally, more than 50 health systems leveraged existing telemedicine programs to provide virtual care during the pandemic.

 At PHS, we rapidly transitioned established virtual visit platforms to enable chronic disease management and urgent care access, addressing conditions that may otherwise lead to hospitalizations. In April to May 2020, virtual visits accounted for nearly 60% of total visit volume, with 330,000 completed visits. Similarly, an existing e-consult program was expanded to increase access to specialty care without an in-person visit. One of our academic medical centers has seen the proportion of e-consults among total referrals increase from 8.5% to 19.6% since March 2020.

There is increasing recognition that telemedicine helped mitigate the consequences of delayed care due to COVID-19 and could replace aspects of in-person care.

 However, the proliferation of telehealth also requires a deliberate focus on health equity. Within our system, equity programs collaborated to reduce the “digital divide” by increasing patient portal enrollment, distributing educational materials in multiple languages, and using SMS text messaging applications for virtual health. After the pandemic, further efforts will be needed to evaluate telemedicine and to ensure that all populations have access to its benefits.

Population Health as the Foundation of Care Delivery in the Post–COVID-19 World

In the near term, health care systems may understandably focus on volume to recover lost revenue and may worry that participation in accountable care organizations could increase financial risk due to the unknown impact of COVID-19 on contract performance.

 However, population health management will have an essential role after COVID-19 to support financial recovery and to lead the transformation of health care delivery.

Financially, capitated contracts and shared savings payments can allow continued cash flow during the pandemic. Risk coding can ensure adequate reimbursement and federal stimulus funding by identifying the complexity of COVID-19 cases. Network management programs can help recover referral volume as nonessential procedures are resumed. In the long term, population-based payment models, like capitated or subcapitated contracts, can enable health systems to flexibly deploy clinical programs to meet evolving patient needs and slow the growth of health care spending.

After the pandemic, population health programs can lead the development of a resilient health system (Table). The analytics, proactive outreach, and program innovation that drove success during the initial COVID-19 surge can help prevent a resurgence by delivering tailored services. Clinical registries and risk prediction models can identify patients at highest risk of poor outcomes, and high-risk care management should expand to flexibly respond to medical and social needs. Telemedicine should be recognized as an essential tool to minimize low-value care while improving efficiency and patient experience. Robust postacute and behavioral health programs will be needed to manage future capacity for convalescing patients and to address the ongoing mental health challenges of COVID-19. Interventions to identify health inequities and support digital access should continue to address the disparities highlighted by the pandemic.

 By creating efficiency and improving outcomes, population health can both advance our system of health care delivery and support the changing needs of providers, payers, and patients.

Effective population health management is vital to enable rapid adaptation to public health crises and to promote long-term financial sustainability. Population health should lead as a suite of programmatic initiatives and as a learning system of delivery science to support the evolution of the health care system to be more patient-centered, efficient, and resilient.

Salina Bakshi, MD, MPH, and Katherine H. Schiavoni, MD, MPP, contributed equally to this work and are listed as co–first authors.

The authors would like to thank Michael Esters and Janet O’Malley for their leadership and contributions to the population health management programs described in the article.

 Population Health Management (SB, KHS, LCC, TEC, AOF, BPF, FRK, CTP, JSR, DFT, JHW, GSM, MLM), Department of Quality and Patient Experience (TEC, BPF, TDS), and Data and Analytics Organization (DFT), Partners Healthcare, Boston, MA; Division of Cardiology (JHW), Department of Medicine (SB, KHS, FRK, CTP, JSR, SJB, GSM), and Department of Psychiatry, Depression Clinical and Research Program (TEC), Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Emergency Medicine (LCC), Division of Nephrology (MLM), and Department of Medicine (AOF, TDS, GSM, MLM), Brigham and Women’s Hospital, Boston, MA; Division of Geriatric Psychiatry, McLean Hospital (BPF), Belmont, MA; The Mongan Institute, Massachusetts General Hospital (SJB), Boston, MA.

 The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (SB, KHS, LCC, TEC, AOF, BPF, FRK, CTP, JSR, DFT, JHW, SJB, TDS, GSM, MLM); acquisition of data (SB, KHS, LCC, TEC, AOF, BPF, FRK, CTP, JSR, DFT, JHW, SJB, TDS, GSM, MLM); drafting of the manuscript (SB, KHS, LCC, TEC, AOF, BPF, FRK, CTP, JSR, DFT, JHW, SJB, TDS, GSM, MLM); and administrative, technical, or logistic support (SB, KHS, LCC, MLM).

 Mallika L. Mendu, MD, MBA, Department of Quality and Safety, Brigham and Women’s Hospital, One Brigham Circle, Boston, MA 02115. Email: mmendu@partners.org.

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Articles

The authors detail how population health management enables health systems to promote public health, strengthen health system resiliency, and support financial recovery during and beyond coronavirus disease 2019 (COVID-19).

Lucas C. Carlson, MD, MPH

Articles

The Essential Role of Population Health During and Beyond COVID-19