Population Health Strategies to Advance Health Equity: A Q&A With Dr Paul G. Alexander

As ​​COVID-19 illuminated the disparities in health care access and quality that exist nationwide, health systems were challenged to not only identify populations in need, but develop strategies that prioritized continuity of care and communication among historically underserved communities.

At this year’s Health Equity Summit, in San Diego, California, Paul G. Alexander, MD, MPH, executive vice president and chief health equity and transformation officer, RWJBarnabas Health, addressed the population health management strategies his organization has designed and implemented to reduce health inequities.

Describing the pandemic as an “opportunity” for health care systems to better address these disparities, Alexander spoke with The American Journal of Managed Care^® (AJMC^®) on the critical care and social issues prevalent among the patient populations RWJBarnabas Health serves, the importance of community-level partnerships in improving these outcomes, and further efforts warranted in the pursuit for health equity.

AJMC^®: You recently participated in a panel discussion at the 2023 Health Equity Summit on population health management strategies to reduce health disparities. Can you speak on some of the key themes of your session?

Alexander: The session explored efforts to increase access to health care and improve health outcomes for vulnerable populations. At RWJBarnabas Health, we are particularly focused on addressing the needs of vulnerable people in the diverse geographic areas we serve. We are partnering with community organizations within our service areas to improve access to care and health outcomes for vulnerable populations.

RWJBarnabas Health is an anchor institution committed to delivering comprehensive clinical care and addressing the social needs of the communities we serve. We work with community-based organizations, faith-based organizations, and local health advocacy groups that align with our anchor mission. One such partnership is with our community health workers who live and work in some of our most vulnerable communities. Our community health workers assist us with outreach to these vulnerable populations and significantly improve our efforts to address the needs of individuals and the community needs.

From a medical perspective, we look to address the social determinants of health [SDOH], such as housing and food insecurity, that influence health outcomes. Once we identify these insecurities, we partner with community-based organizations to optimize our ability to serve these patients' clinical and social needs. This coordination is ultimately going to improve health outcomes.

An essential element of improving overall health is improving access to care. If we can improve access to care, we can improve overall health and address many of the insecurities that impact our patients, such as housing and food.

AJMC^®: In centering on the community-level health inequities prevalent among the patient populations you serve, what lessons did RWJBarnabas gain from the COVID-19 pandemic, and how has this influenced the strategies you have helped design and implement?

Alexander: COVID-19 illustrated the disparities that exist among populations. It presented the world and, more specifically, health care with an opportunity to address these disparities differently. We had to think outside the box about coordinating care for patients who could not come into the hospital and how to continue delivering much-needed social services within our communities.

During the height of the pandemic, our goal was to maintain continuity of care and communication with our patients. We coordinated transportation for patients from the hospital to their homes, did follow-up visits in the homes post–acute discharge from the hospital, and worked with our case managers and community health workers to communicate with these patients.

RWJBarnabas focused on the decompression of our hospital beds and the emergency room, as well as addressing the issues of medication access. Partnering with pharmacy on the delivery of medication was critical, as well as improving food insecurities.

We believe food is medicine—I think it's highly unlikely for patients to take medications if they don't have food—so we partnered with organizations to deliver meals within our service areas.

To some extent, the pandemic is still going on; we're still facing individuals who fear being in the health care environment. Staffing shortages and burnout is an additional challenge. During the pandemic, we experienced employees who were overstressed and decided to explore alternate careers. We continue to manage these issues.

AJMC^®: For health systems just beginning in their journey toward identifying and addressing health disparities, what factors should be top of mind, and what are some best practices for creating population health management strategies respective to the communities they serve?

Alexander: A considerate amount of attention has to be paid to SDOH, with the understanding that one size does not fit all. When you're talking about patient populations, you're looking at diverse groups—diversity in ethnicity, diversity in individuals who are dealing with behavioral disorders—and to be effective in assisting these patients, we have to take into consideration the variables that might impact our ability to address health disparities.

We utilize a survey for the SDOH to gather information on our patient populations. We look at indicators such as emergency department [ED] visits, extended hospitalizations, and readmissions. We try stratifying patients to identify the challenges and address their concerns and needs.

Creating population health management strategies is going to take a concerted effort. We need to understand the variety of populations we serve and how a health system can integrate into these communities. We need to engage with and address the fears of the most vulnerable that lead to avoidance of care. The lack of trust and the belief that they won't get the needed care has to be top of mind.

Case managers are vital to improving health outcomes; they can build relationships with patients and perform the outreach necessary to improve health outcomes. I want to stress that we must remain mindful that one size is not fitting all. We must develop initiatives that make sense for specific groups to promote engagement and work with doctors, nurses, case managers, etc, to improve care outcomes, regardless of faith, ethnicity, disabilities, etc.

AJMC^®: What gaps remain in optimally identifying and addressing health disparities? And how should the effectiveness of these initiatives be measured short and long term?

Alexander: As we try to optimize health care delivery and tackle the disparities that negatively impact outcomes, we engage community-based organizations for assistance. I do find that one of the biggest challenges for us is that community-based organizations often don't have financial resources that are important for them to accomplish their mission. We've also found that there are a lot of concerns in terms of technology and connectedness.

Ideally, we want to identify those needing help and develop trusting relationships effectively.

So, we screen for SDOH using our computer-based programs. We have MyChart, an electronic medical record shared with our providers. We use that to build many of the assessments performed, particularly around SDOH screenings. About 74% of our population in need participate in the Supplemental Nutrition Assistance Program [SNAP], so we do our best to continue to enroll those individuals and increase awareness of that program.

We also have created a voucher program for individuals not participating in the SNAP program who would benefit from additional food services from either the New Jersey Food Bank or from one of our farmer's markets at the facilities in the system. And by granting vouchers, we can provide food to individuals who don't have SNAP and may not have the funds to purchase food. The coupons will give them access to the foods that they need.

Of the group of metrics that we follow, the one that I think is most relevant is the number and percentage of connections with our patient populations. We look at our success rate, consider if an individual is more likely to use their mobile device vs their home device, and send text messages to improve connectivity with the patients in need.

In addition to connectivity, we track ED utilization and hospital admissions to identify underserved populations. And with monitoring these metrics, we can assess patient needs and our performance, as well as understand if we are making a difference in the services we deliver to the communities.

AJMC^®: What is a disparity in health care that you think doesn't get as much attention as it should?

Alexander: As we look at disparities and the challenges that individuals are living within the communities, I focus on what we are doing in terms of our clinical management to address internal factors that might prevent optimal outcomes.

At RWJBarnabas Health, we've created an antiracism initiative, the Ending Racism Together program, which involves educating providers on the issues occurring in disadvantaged populations or underserved populations, and on their biases, implicit biases that they might not be aware of, that may interfere with the development of trust between patients and providers, as well as interfere with developing an effective treatment plan for that patient.

When you go to medical school as a physician, you don't feel you're practicing health care in a biased way. But there are sometimes biases we're unaware of that could interfere with optimal health outcomes. I don't think many would admit to doing that.

So, our goal is to look internally at what we can do to improve the educational programs for our providers, as well as look more closely at those social determinants that interfere with the health outcomes and having that information as part of the medical chart so that everyone who's engaging this patient will have access to the same information.