Case Studies
INTEGRATING DATA
Presbyterian Health: Utilizing Integrated Data Infrastructure as Foundation for Robust Population Health Framework
Presbyterian Health utilized an existing population health model, along with systemwide data and infrastructure, to conduct proactive COVID-19 risk assessment and outreach, reduce disparities, and use remote monitoring for preventive care.
Presbyterian Health needed to identify and engage populations at risk for COVID-19 in order to reduce health disparities and adverse outcomes among diverse populations, help adapt virtual solutions for preventive care and disease management, and keep patients safe and out of the hospital.
- Analyzed real-time clinical data, claims, SDOH, and behavioral health data to create a complete health picture for each patient and the population
- Identified care gaps and patients with rising risks due to SDOH
- Offered proactive solutions:
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Preventative care (eg, telehealth)
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Individualized outreach (eg, medication delivery)
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Chronic disease management (eg, healthy meal deliveries)
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- Implemented remote monitoring (eg, oxygen levels, temperature) to enable select members diagnosed with
COVID-19 to safely recover at home
- Identified >20,000 members at risk for adverse COVID-19 outcomes using systemwide data
- Shifted 80% of primary care visits to telehealth to ensure continuity of preventative care
- Avoided hospitalizations and ED visits with remote monitoring
- Reduced COVID-19 exposure with home delivery of chronic condition medications
- Stressed importance of lifestyle management with the delivery of 2 weeks of healthy meals
For more information, visit Becker's Hospital Review
ED=emergency department; SDOH=social determinants of health.
Robran-Marquez D. Addressing patient and member needs during the pandemic: a robust population health framework is key. Becker’s Hospital Review Website. https://www.beckershospitalreview.com/care-coordination/addressing-patient-and-member-needs-during-the-pandemic-a-robust-population-health-framework-is-key.html. Published August 5, 2020. Accessed August 21, 2020.