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Bridging gaps: Data-driven approaches to patient outreach

By Lisa Carter, Writer at Arcadia
Patient Engagement Population Health Management

Utilizing data-driven strategies to connect with patients on a personal level

In the world of primary care and population health management, engaging patients is of utmost importance. The COVID-19 pandemic has highlighted the need for healthcare providers to reach out to patients individually, understand their unique care needs, and improve their outcomes. However, this level of personalized engagement is not feasible at scale.

This article explores the power of data-driven approaches to patient outreach and how they can bridge the gaps in patient care. We addressed this topic on a Byte-Sized Booth Talk at HIMSS, which features Anna Basevich, SVP of Enterprise Partnerships and Customer Enablement at Arcadia. Basevich speaks about the importance of effective patient engagement and shares best practices for implementing data-driven patient outreach strategies.

Understanding the population: Stratification and tailoring

To effectively engage patients, healthcare organizations must first understand their population Stratification is a crucial step in this process. As Anna Basevich emphasizes, merely dividing patients into low-risk, rising-risk, and high-risk cohorts is not enough. Each cohort comprises individuals with unique needs and contexts. The key is to dive deeper and create more tailored and customized groups within these cohorts.

Low-risk population: Targeted education and leveraging technology

The low-risk population typically consists of young and relatively healthy individuals who may not see immediate value in routine primary care. However, it is essential to educate them about the significance of preventative care and regular check-ups. For instance, when reminding patients about cancer screenings, it is essential to address their age-specific needs to increase response rates.

Since the low-risk population is generally more tech-savvy, healthcare providers can leverage technology to engage them effectively. Utilizing platforms like MyChart for virtual visits and appointment scheduling can make healthcare more accessible and convenient for these patients.

Rising-risk population: Tailored communication and identifying barriers to care

The rising-risk population includes patients with early-stage chronic diseases or specific healthcare challenges. To engage this group, healthcare providers must tailor their communication to each patient's condition. This could involve providing evidence-based guidelines and emphasizing the value of primary care for managing chronic conditions.

Additionally, identifying barriers to care is crucial for this population. Leveraging data to understand preferred contact languages, transportation challenges, or affordability concerns can help providers remove obstacles to care and improve patient engagement.

High-risk population: Vigilant and targeted engagement

The high-risk population requires vigilant engagement to ensure they do not miss essential follow-ups and care. Personalized and rapid outreach is vital in this scenario. Healthcare providers can use technology to schedule follow-up visits, send educational materials, and offer support through care management programs. Engaging family members can also be beneficial in coordinating care and ensuring patients receive the necessary attention across their care continuum.

Data-driven tools for patient engagement

Data-driven tools play a significant role in patient engagement and outreach. These tools help healthcare providers identify patients who can benefit from specific outreach efforts. They can also help address social determinants of health and behavioral health challenges.

Behavioral health impact scores

One impactful use of data-driven tools is building behavioral health impact scores for patients with chronic conditions and behavioral health challenges. These scores help identify patients who could benefit from behavioral health interventions to improve both their behavioral health and traditional medical outcomes.

Addressing social drivers of health

Data can be leveraged to create registries around social drivers of health, such as language barriers, transportation challenges, or affordability issues. Understanding and addressing these factors in patient messaging can break through barriers to care and foster patient engagement.

High-risk maternity registries

For high-risk maternity patients, data can be used to identify opportunities for early engagement and consistent support. Leveraging EHR data and monitoring patients' health status can help healthcare providers intervene promptly and improve maternal and infant outcomes.

Best practices for implementing data-driven patient outreach

Basevich offers some best practices for healthcare organizations looking to implement data-driven patient outreach strategies:

  1. Leverage Data for Stratification: Use data to identify actionable cohorts of patients for targeted messaging and engagement.
  2. Tailor Communication: Ensure patient outreach resonates with individuals by personalizing messages based on their conditions and preferences.
  3. Understand Barriers to Care: Collaborate with care managers and social health workers to identify patient concerns and address potential obstacles to care.
  4. Empower Providers: While data is essential, it should never replace genuine human conversation. Providers should use data as a tool to inform and complement their understanding of patients' unique needs and experiences.
  5. Consistency and Speed: Consistent and timely patient follow-up can make a significant difference in patient outcomes, especially for high-risk populations.

Key takeaways in data-driven approaches to patient outreach

Data-driven approaches to patient outreach hold immense potential for improving patient engagement and care outcomes. By using data to stratify populations and tailoring messaging accordingly, healthcare providers can bridge the gaps in patient care.

However, it is essential to remember that data is a tool to enhance, not replace, human connection and empathy in healthcare. By combining data insights with genuine understanding and support, healthcare organizations can create meaningful patient engagement that leads to better health outcomes for all.

Watch more Byte-Sized Insights or request a demo to see how we can put your data to work, together.