Population health management tools

Helping healthcare organizations improve the health of the populations they serve through personalized digital engagement touchpoints

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Address population health challenges

Many people face barriers to healthcare because of where they live, their race or ethnicity, their education level, and many other factors. In fact, a person’s ZIP code is often more important than their genetic code, with only 10% to 20% of an individual’s overall health stemming from the clinical care they receive, while as much as 40% to 50% can be attributed to social and economic factors.

Get Well’s integrated digital engagement platform helps healthcare organizations democratize access to all patients by helping organizations improve engagement with routine clinical care and guide patients through high-risk episodes of care, including maternity care, surgical procedures, and discharge from the hospital

Our digital engagement platform can also help healthcare organizations extend the reach of their existing resources to help them more efficiently and effectively reach vulnerable patients. Get Well helps organizations address patients’ underlying non-clinical needs by enabling them to more accurately assess social determinants of health (SDOH) risk factors and connect patients to the right resources to help mitigate those factors. 

Improve overall health outcomes 

Understanding the health — and health risks — of a population is vital to ensuring successful population health management. The ability to predict patient behavior or anticipate health decline, build and maintain lifelong relationships with your patient population, and gain real-time insights into the health and healthcare experience is invaluable to providers, health systems, and health plans. 

But it’s also challenging. Inefficient, outdated, and expensive tools often result in inaccurate information, which leads to poor outcomes and high costs for organizations.  

Get Well’s digital engagement platform helps healthcare organizations better support both clinical and non clinical needs of the populations they serve. Our solutions:

  • Improve outcomes by guiding patients through complex, high-cost procedures
  • Reactivate dormant patients
  • Engage underserved populations in routine clinical care to help address care gaps
  • Improve documentation of SDOH risk via longitudinal SDOH assessments
  • Increase referral and conversion of highest impact patients via smart referrals to SDOH programs
  • Reduce out-of-network patient leakage and ensure smooth handoffs of care following procedures or ED visits

Spotlight on health equity

Health equity is when everyone has the same opportunity to be as healthy as possible, regardless of their social position in a community or other social determinants. Social determinants are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health.

Health inequities arise when there are differences in health status or distribution of health services among or between populations that are avoidable and that lead to unfairness and injustice in healthcare. Differences in quality of life, access to healthcare, rates of disease or death, and length of life between groups of people reflect health inequities. 

Operating more than 130 hospitals across 21 states, CommonSpirit Health, the largest nonprofit health system in the United States, brings an empathetic approach to care with the goal of addressing the needs of underserved populations and improving health equity. To navigate this clinical care transformation, the health system partners with Get Well to leverage the Docent Health solution.

Recognizing that Black and African-Americans are more likely to die during pregnancy than those in all other racial/ethnic groups, CommonSpirit Health focused on use of community navigators in addition to digital technology to ensure patients were engaged with its services. 

The result: CommonSpirit Health saw similar bidirectional engagement among all people engaged*, with a 64% engagement rate. Black and African-American people also have a 63% engagement rate, while Hispanic people have an even higher engagement rate of 71%.

Learn more about how hospitals and health systems can use technology to improve care quality and access for all in this on-demand webinar, Serving the Underserved: A Conversation with CommonSpirit Health about Equity in Healthcare.

*Data as of November 2021

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Recommended resources

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