Effective population health outreach can lower costs per service, reduce Emergency Department visits and hospitalizations, and generate better patient experiences, engagement, and outcomes. However, this requires a significant cultural shift from episodic care to holistic, ongoing wellness and disease prevention.

Most people wait to call the doctor until they are sick and want to feel better. But how many reach out to schedule appointments when they’re feeling fine?

Routine care is the key to staying healthy and preventing disease, yet many patients neglect to schedule regular screenings such as mammograms and colonoscopies. And others with chronic diseases like diabetes or hypertension don’t regularly visit the doctor to proactively manage their conditions.

Population health outreach must be personalized and automated for healthcare providers and payors to successfully engage patients in preventative care. Manually tailoring messages for each patient would be impossible and inefficient, but today, technology is helping health organizations address disparities in care by targeting specific populations at scale.

Launching a population health outreach campaign can seem daunting, but the right data analytics and technology can help identify and group patient populations using various criteria. Here are three different ways to target patients for successful population health outreach.

Patients with Specific Chronic Disease

Chronic disease is one of the top causes of death, disability, and inflating healthcare costs in the United States. That’s why helping chronic patients effectively manage their disease is critical to improving outcomes. Effective population health management requires engagement with patients, before, during, and after medical appointments. Chronically diseased patients want individualized treatment and tools for managing their condition, and automated population health outreach makes this possible.

Population health outreach can be tailored for a variety of common chronic conditions, including:

  • Asthma
  • Diabetes
  • Congestive Heart Failure (CHF)
  • Coronary Artery Disease (CAD)
  • Chronic Obstructive Pulmonary Disorder (COPD)
  • High-Risk Obstetrics
  • Mental Health
  • Obesity

The right technology can help you identify patients in each of these categories through seamless integration with your EHR. With capabilities for advanced reporting and analytics, leveraging technology to target populations with chronic diseases can make population health outreach can be even more targeted. For example, in a population health outreach campaign for patients with diabetes, healthcare providers and payors could target patients with HBA1C levels above 8 who have also not been to the doctor in the past 90 days.

This personalized population health outreach delivers resources at scale to help patients demonstrate self-care and receive continuous support beyond the clinical setting. Clinical messaging can increase engagement, and when a patient deviates from their care plan, automation can inform the care team, allowing them to intervene in a timely manner.

Patients Demonstrating Risk Factors

Similarly to targeting patient outreach for those with chronic conditions, technology can also help you identify and sort patients demonstrating various risk factors based on various attributes, including:

  • Advanced age
  • Demographics
  • Diagnoses
  • Economic Status
  • Hereditary Diseases
  • Utilization History

Using technology and data to inform risk stratification can help deliver care targeted to each patient’s individual needs and risks. Patients with a higher risk can be targeted for population health outreach campaigns that may provide care plan adherence advice, patient support programs, or social and community follow-up. For example, population health outreach campaigns could target high-risk adults between the ages of 55-80 who have used tobacco within the last 15 years, prompting them to schedule lung cancer screenings or encouraging them to join smoking cessation programs to lower their risk.

For women’s health, early detection in breast cancer can be the difference between life and death. Annual mammograms are critical to catching and managing breast cancer early, although many women fail to schedule these appointments every year. Automated and targeted population health outreach can ensure regular screenings stay top of mind for women above 40, which can reduce their risk of breast cancer by 66%.

Patients with a lower risk score may still be targeted for services such as preventative screenings and vaccinations, or alternative care options such as virtual communication with their providers for minor health issues and incentives for healthy habits. Patients may not always need to physically see their doctor stay healthy. When patients receive educational resources from their care providers, they’re more likely to respond by taking measures to maintain good health as a lifestyle. This reduces the need for acute care while improving the wellness of the patient.

Providing preventative service options through population health outreach for targeted at-risk groups can help each patient maintain the highest possible quality of life while avoiding crisis events and expensive services.

Patients Due for Annual Physicals and Vaccinations

Finally, population health outreach can target various age groups to provide preventative, annual care for all age groups, including:

  • Birth to 15 Months
  • 3-6 Years
  • Adolescents
  • Adults
  • Geriatrics

Preventative care is foundational to keeping patients healthy. Using automation in population health outreach allows healthcare providers and payors to ensure their entire patient population is covered. Patients can receive reminders about critical screenings, vaccinations, such as the flu shot, and other preventative care necessary to maintain wellness. Proactively delivering these messages gets patients in the door before it’s too late.

When patients are actively engaged in their care plan, quality outcomes are better because it brings the responsibility and focuses on health back to the patient. And as value-based care incentives continue to accelerate, it is critical to reaching your patient populations in an effective and scalable manner.

With technology-enabled population health outreach, communications can be targeted to myriad population groups for greater personalization, engagement, satisfaction, and outcomes for your patients. Preventative care is typically underutilized, but automated and targeted population health outreach can ensure patients understand what they need to do to take good care of their health.

Want more? Learn more about designing population health outreach at your organization.