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9th Annual Rock Health Summit 2020: Delivering Digital-First Collaborative Care for Vulnerable Populations

On September 22, 2020, Chris Klomp, CEO of Collective Medical, presented on a panel at the 9th annual Rock Health Summit. Moderated by Michael Petersen, MD, Health Equity Lead at Accenture—and together with Abner Mason, Founder and CEO of ConsejoSano and Sonia Millsom, Chief Commercial Officer at Maven Clinic—the group focused their discussion on how providers and payers can use digital technologies to more effectively deliver care to high-needs patients. 

Dr. Petersen began by sharing a quote by James Baldwin:

“Not everything that is faced can be changed, but nothing can be changed until it is faced.”

The premise of the discussion was this: patients with complex needs generally don’t and can’t have their needs fully met at any single point of care. This makes communication and collaboration essential to achieving desired clinical outcomes. But the level of collaboration is not currently feasible under a strictly physical care model given the complexity of needs spread across a high volume of vulnerable patients served by a discrete number of providers.

So how do we meaningfully address the unique issues faced by vulnerable patient populations by leveraging a digital-first approach? And how do we ensure that vulnerable patients don’t slip through the cracks due to various health inequities that prevent them from accessing that digital or physical care?

Health Inequity Struggles Facing Vulnerable Patient Populations

Dr. Petersen asked Millsom how the healthcare industry ensures equitable access when leading with digital tools, particularly in regards to maternal care. Millsom emphasized that healthy babies start with healthy mothers and families.

She shared that historical support systems such as parents, aunts and uncles, or friends who might otherwise help expectant and new mothers get to the doctor or during the postpartum period have become much more challenging in the face of the COVID-19 pandemic.

Maven Clinic creates customized care teams—including OBGYNs, lactation consultants, and mental health providers—by first questioning who should be part of a patient’s care team. By creating these multiple touchpoints and addressing needs such as transportation or digital access, Maven Clinic is able to better support patients and their families.

Mason shared that if there’s one thing that COVID has taught us, it’s that it’s been the great revealer rather than the great equalizer. The pandemic has revealed in stark ways how our healthcare system isn’t working for everyone. Because it isn’t designed to meet patients where they are.

ConsejoSano uses data to better understand patients and customize its message for each individual—treating them in ways that are culturally relevant rather than treating them the same as every other patient as if who they are doesn’t matter. By recognizing differences and adapting, ConsejoSano is able to build trusting relationships with each of its patients.

Logically Tuned IT Infrastructure

During the panel, Dr. Petersen asked Klomp the following question:

“What does a logically tuned IT infrastructure mean to you and how do we bring that to vulnerable populations?”

A logically tuned IT infrastructure is focused not only on technical interoperability (moving data from point A to point B) but clinical interoperability—or how to generate high-value insights and place them in front of the right provider at the point of care.

While digital-only isn’t the answer, starting with a digital-first approach enables providers to leverage technology that provides the biggest bang for their buck in regards to empowering them and extending their reach into their individual communities.

This type of solution is automated and integrated within care team workflows, and provides a comprehensive view of a patient’s care history. By closing information gaps, care teams can better treat both behavioral and physical health, along with addressing social determinants of health, such as food insecurity, unstable housing, and low income.

Additionally, Klomp shared that a digitally-tuned IT system is anticipatory rather than forcing providers to spend time sifting through data, searching for clinically relevant information.

“It’s figuring out how to empower providers to do more. It’s not asking them to do more. It’s not making them look for information. It enables humans to do what humans do best—which is engage and care for other humans.”

Ron’s Story

To illustrate the intersection of digital health, physical care, and vulnerable patients, Klomp shared a story about a patient named “Ron.” Based in the Portland area, Ron had patterns of high emergency department (ED) utilization. At his peak, he visited the ED 23 times across seven different hospitals at all times of the day.

Ron always presented with a new injury or symptom—usually resulting in an opioid prescription. With technology, his care providers were able to stitch together disparate visits and identify a pattern. He was managed by a primary care provider, and his care service coordinator started being notified each time Ron presented at an ED once Collective’s platform became available across Oregon.

In a testament of good people doing good things in healthcare, his coordinator would immediately notify the hospital that he was coming, get into his car, drive to whichever ED Ron was at, and meet with him to ensure he received the best possible care for his needs.

As it turns out, Ron had several developmental disabilities, diabetes, and a number of social determinants that were affecting his health. He was homeless, living in his truck, and though he had a phone, he had difficulty keeping it charged without access to stable housing.

Now, Ron has built a relationship with the care service coordinator, and each time Ron presents at an ED, care team members can all follow a consistent plan of care. He’s getting his medications without unnecessary narcotics. His diabetes and blood pressure are under control and are being managed.

Ron still visits the ED occasionally, but his peak visit count is down to three from 23. He’s surrounded and supported by care providers across his community.

Dr. Petersen wrapped up the session by emphasizing that policy shifts move with data and that we’re currently in a moment to make change rather than admiring the problem without meaningful action. If you registered for the Rock Health Summit, you can watch the recording here.

Brittany Eastman
Content Marketing Specialist