A person's zip code is a highly predictive determinant of their health. Clinically integrated health networks must account for and manage neighborhood-level variation in clinical and social determinants to improve community health, care experiences, and cost.
In this podcast, BVK and partner Wellforce's population health leaders will share an approach for building healthy communities that starts with neighborhood-level care teams and the patients that they serve and share. Our approach leverages data analytics, the marketing discipline, and innovative network-of-networks models to focus resources and interventions and improve population health neighborhood outcomes.
There are critical lessons for marketing in this approach, notably, how to "show-up" in the effort to build healthy communities and how to contribute essential insight into building effective interventions that deliver on the brand promise of improving health and wellness, not simply organizing and operating hospitals and physician practices.
Learning Objectives
• Recognize the core components that determine the health of a population neighborhood
• Apply a data methodology to define and organize population health neighborhoods
• Know the care continuum gaps that must be addressed to improve neighborhood health
• Define and measure success in terms of improved neighborhood population health and wellbeing
Selected Podcast
Building Population Health Neighborhoods: Learn How a Person’s Zip Code Can Actually Determine Their Health
Featured Speakers:
Dr. Cardoso is a leader in developing and executing population health strategies for the Lowell General Hospital PHO. In addition, Dr. Cardoso maintains an active pediatric practice, and provides population health counsel and support for Wellforce, Lowell General Hospital’s parent integrated health system.
Dr. Cardoso attended George Washington University Medical School and completed her Residency and Pediatric Hospital Medicine Fellowship at Floating Hospital for Children at Tufts Medical Center. She is active nationally with the Academic Pediatric Association and serves in many roles including the Medical Executive Committee at Lowell General Hospital.
Michael Eaton | Megan Cardoso, MD | Adam Russman
Michael Eaton is Senior Vice President, BVK Health.Dr. Cardoso is a leader in developing and executing population health strategies for the Lowell General Hospital PHO. In addition, Dr. Cardoso maintains an active pediatric practice, and provides population health counsel and support for Wellforce, Lowell General Hospital’s parent integrated health system.
Dr. Cardoso attended George Washington University Medical School and completed her Residency and Pediatric Hospital Medicine Fellowship at Floating Hospital for Children at Tufts Medical Center. She is active nationally with the Academic Pediatric Association and serves in many roles including the Medical Executive Committee at Lowell General Hospital.
Adam Russman is a healthcare analytics thought leader with achievements in strategic planning, analytics, business development, and product management. He focuses on
translating strategic direction into tangible actions for his colleague and teams, focusing on individual accountability and mentorship. Adam currently heads the analytics function at Wellforce’s clinically integrated network. His previous experience includes analytics at New York-Presbyterian, lecturer on analytics at Columbia University, VP of Customer Success at an Artificial Intelligence startup, and management consultant at PA Consulting. He holds his MBA/MS in Healthcare Leadership from Cornell University, an MS in Economics, and BA in Mathematics from Tufts University.
translating strategic direction into tangible actions for his colleague and teams, focusing on individual accountability and mentorship. Adam currently heads the analytics function at Wellforce’s clinically integrated network. His previous experience includes analytics at New York-Presbyterian, lecturer on analytics at Columbia University, VP of Customer Success at an Artificial Intelligence startup, and management consultant at PA Consulting. He holds his MBA/MS in Healthcare Leadership from Cornell University, an MS in Economics, and BA in Mathematics from Tufts University.
Transcription:
Building Population Health Neighborhoods: Learn How a Person’s Zip Code Can Actually Determine Their Health
Intro: The following SHSMD podcast is a production of DoctorPodcasting.com.
Bill Klaproth: So do you know the health needs of the population you serve? And if so, are you developing services to meet those needs? Hmm. I ask you this question. Well, let's talk about building population health neighborhoods. This is a really important topic and learn how a person's ZIP code right in your community can actually determine their health, giving you valuable insight into their needs. So let's talk about it with Adam Russman, Director of Data and Analytics at Wellforce; Dr. Megan Cardoso, a Medical Director of Population Health at Wellforce; and Mike Eaton, Senior Vice President of BVK Health. And this episode is sponsored by BVK Health. So let's get into it right now.
This is the SHSMD podcast, rapid insights for healthcare strategy professionals in planning, business development, marketing, communications and public relations. I'm your host, Bill Klaproth. And in this episode, we talk about building population health neighborhoods, and learning how a person's ZIP code can actually determine their health with Adam Russman, Director of Data and Analytics at Wellforce; Dr. Megan Cardoso, a Medical Director of population Health at Wellforce; and Mike Eaton, Senior Vice President at BVK Health. And this episode is brought to you by BVK, an independent business marketing and advertising agency with expertise in delivering purpose-driven healthcare experiences that impact lives, build healthy communities and shift societal health behaviors. Visit them at bvk.com/rapidinsights to schedule a private session with one of their health experts today.
Dr. Cardoso, Adam and Mike, welcome to the SHSMD podcast. We start every episode of the SHSMD podcast with rapid insights. One quick tip someone can use to make their marketing communications better today. Mike, let's start with you. Give us your rapid insight
Mike Eaton: There's a really critical shift in how you should think about your strategies, you think about communicating to your customers. And it starts with changing the question. From asking "How are we doing?" to asking "How is my customer doing?" And customer may be an individual. It might be a family. It might be a segment of folks with a particular need. It can be a whole community. But if you start with understanding how your customer's doing, you'll often come up with different answers to the problems that they have or the unmet needs that they're trying to solve for.
Bill Klaproth: Love that. So switch that question to "How are you doing?" Thank you for that rapid insight, Mike. Adam, you're up next. Give us your rapid insight.
Adam Russman: ZIP code should only be five digits or nine digits. Nothing in between will work.
Bill Klaproth: Five digits or nine digits. Let's remember that, people. All right, Adam. Thank you for that rapid insight. I appreciate it. Dr. Cardoso, you are up next. Give us your rapid insight.
Dr. Megan Cardoso: When you're working with physicians and physicians offices on complex topics like building healthy communities, it's important to present all of your information in practical, simple, and effective ways.
Bill Klaproth: That is your rapid insight. Thank you, Dr. Cardoso, Adam and Mike. We appreciate that. Adam, we're going to go to you first as we talk about this great topic, building population health neighborhoods, and we can learn how a person's ZIP code can actually determine their health. So let me ask you this, Adam. Health systems are making the shift from looking for customers to buy the services they offer to developing services to meet population health needs. How does someone in your role help make that shift?
Adam Russman: One of the foundational elements to any health system is how they best leverage and use their data to meet the needs of both their community and the broader organization. The use of data within this context is really to drive insights that help define and generate most high value services that are needed within any type of marketplace. And when you started talking about healthcare, this becomes increasingly important, particularly around different types of clinical services and different types of interventions that you can then drive and drive from data.
So someone within my role is the person who is responsible for gathering, cleaning and preparing data for individuals like our clinicians and other administrators within the hospital systems to derive insights and define what their market plans should be going forward.
Bill Klaproth: You're kind of like a ZIP code hunter. So you're looking for certain things within a community like hypertension or diabetes or other things like that. You go out looking for those types of things?
Adam Russman: You can go out looking for those types of things or like a good metaphor, a good simile, is you act like a fishermen would. You're really trying to review where in the sea you may find activities and individuals. You're trying to cast the line and cast the net to identify those. So you can either use a model where you're hunting and you're trying to find where those are or you let the data speak to you by using some of the later technologies and newer activities to sort of read out what is happening underneath the sea.
Bill Klaproth: Right. So using the fishing metaphor at times. You're just casting the net wide to see what you catch and what turns up.
Adam Russman: Correct. It's not necessarily taking the idea that there must be hypertensives about there. It's looking around your network to say, "It looks like I have a hotspot of cardiac patients in this one geographic region on the south shore of Massachusetts who have certain utilization patterns based on their proximity to different types of services. And by sort of framing the question that way, as opposed to saying, "Tell me where my hypertensives are," you end up identifying more interesting patterns that can come from just naturally reading data.
Bill Klaproth: So then how would a marketer go about extracting this information from ZIP codes? I'm just curious. How do I look at a ZIP code? Where do I go to find out that, "Oh, my gosh, I see that this certain ZIP code has a high prevalence of hypertension." How do you do that as a marketer?
Adam Russman: Lots of people in the data world will know that the first thing you really need to do is get and acquire really clean data. The world has ZIP codes depending on what your systems are and what they look like. Luckily, things like EMR and practice management systems have improved data capture, but you really need to hone in and isolate and get a working ZIP code for an individual patient within your population. And then in using that, you need to then go through a whole exercise of taking those ZIP codes, mapping them in, identifying what towns and what activities get associated to those and then you're tying it into all of your other clinical data that you gather, your quality measures, your clinical activities from your EMR and your claims-based measures to come up with an overarching view and picture of what your population would look like.
Bill Klaproth: Yeah, that is really interesting. I love that data perspective you bring to that. You're mining the ZIP codes to see basically what you can find. So then, as you find some areas of interest or things that are important to you, let me ask you this, Dr. Cardoso, from a physician's point-of-view, what are some of the most stubborn barriers then once you find this information out to building healthy communities?
Dr. Megan Cardoso: That's a great point. I'm actually going to take you a step back there for a second. One of the biggest challenges we have is getting the demographic information that we need. So we may know what people's ZIP codes are, but we don't know what language they speak or what ethnicity they have or where they're coming from.
And as, you know, with COVID and the pandemic, inequities in healthcare have just become so much more prevalent and we've been able to see them more. And so how do you specify and target specific communities based on all those factors? Well, the problem is that a lot of our offices and our PCPs and our hospitals aren't equipped or prepared to ask those questions yet. So I would say to take a step back, I think we need that clean data and really working with our providers and our offices and our hospitals to feel comfortable asking that question and explaining why it's so necessary and relevant.
Bill Klaproth: Yeah, thank you for bringing that up. That's really important. And I'm glad that you said that because, as you're talking about barriers, that seems like one of the ones you first have to overcome. What other stubborn barriers would physicians face?
Dr. Megan Cardoso: Yeah. So pervasive problems like mental health are very big. We find people who have a lot of chronic conditions often also have something like depression or anxiety that go along with it. Sometimes it's identified, sometimes it's not. But we know that people who have depressive disorders for example are utilizing more often.
There's lack of access to healthy food for diabetics. There's lack of good family and social supports for people. And as we think about transitioning most of our healthcare from the hospital, which has always kind of been the hub of our healthcare, as we're transitioning that to more "How do we take care of people in their homes, in their communities?", it's important to think about how do we get the resources we need to take care of them into those homes and into those communities.
Bill Klaproth: Yeah, that's a really good point about that transition again from the hospital to care in the home or the community. So can you give us an example of all this, kind of a real world look at how this works?
Dr. Megan Cardoso: Sure. A team of physicians came together and said, "What are one of these barriers that is preventing equitable care that we want to tackle first?" And so we, as a group, came together and said, "Depression is something that is pervasive in our community. It crosses all socioeconomic ZIP codes, et cetera." And so we thought about depression and we built out a playbook for our physicians and our offices.
It really thinks about a couple of things. So one is how do you standardize screening across the board, all ages, all demographics, all languages to identify depression? And then once you have identified depression, what do you do? What's the next step? How do you integrate behavioral health into primary care in p laces where resources are low? So we have built out a playbook for our physicians, that's just kind of a step-by-step, "This is how you screen. This is how you refer someone to the program. This is the followup. This is how we gather data. Here's some resources for your patients. Here's some prescribing guidelines." So again, very simple polished guidelines that are easy and quick reads for our patients.
Bill Klaproth: And generally, are physicians receptive to this information?
Dr. Megan Cardoso: Very receptive. Everyone in busy clinicians offices, we don't have a lot of time to spend with all of our patients going through all of this. So, with standardized screening and then teams that can help us with our depressed patients, people have been very receptive to this.
Bill Klaproth: Wow. That's really good to hear. So Adam has kind of went and found the information we need. Dr. Cardoso has put together a playbook for the physicians. Mike, how do we put this together from a marketing role? How do you see marketing playing a role in population health strategy and activation?
Mike Eaton: I think marketing has a really big role to play in population health. And one of the concerns that I have often is that marketers don't see that. So there's a sense that that happens someplace else. There's a couple of things that are really critical. One is in marketing. A core function that marketers play is identifying needs, unmet needs, where there's opportunities, gaps in the communities that we serve and the populations we serve them in our customer base.
So as Adam talked about those data tools, and as Dr. Cardoso talked about the importance of having not just ZIP codes, but also demographic data, understanding language, understanding a whole series of variables that impact how people make healthcare decisions. We know there are a lot of databases that marketing has access to be able to fill in some of that qualitative insight and data, as opposed to just the quantitative of who lives here and some basic demographics. So marketing has a big role to play there.
Second area marketing has a big role to play is when we think about how the story gets told. And Dr. Cardosa was referencing that, that it's important not simply to take a really complex topic like this and drop it on physician practices that are busy. They're already managing lots of data. They have a lot of information that flows through their practices. But how can we put it together in a way to tell stories?
We know that storytelling has helped people learn. We know that if we can bundle these things up in playbooks and tool kits and different types of things that are really well done, polished, simple, clean, taking the complex, making it simple, we have a much higher likelihood of people actually putting those things to use. And that's what creates the impact in the communities. It's taking the work that Adam does to identify where there are opportunities for us to intervene, the work that Dr. Cardoso does to design highly effective interventions, and then that role of marketing can help to plate, to take that information and put it out there in a way people can use it.
Bill Klaproth: So for a marketer listening to this, what is the first step in doing what you just said, having that information at your fingertips, your hands, if you will, and then, "Okay, I've got this information. What do I do first?" I know you talked about storytelling, but kind of give us a roadmap for a marketing director. What should that person do with this info?
Mike Eaton: Well, the first thing is to not presume that you're on the sidelines when it comes to population health. So it's to make that commitment to plug in to population health development efforts, developing strategies in particular markets and regions and thinking about how to communicate, how to change people's behaviors. And that's an important first step, is to know that you're relevant to the process.
The second is, as Adam talked about, it's understanding what data do we have, where do we have gaps in our data to be able to identify the things that Dr. Cardoso also spoke of in terms of kind of the qualitative variables which influence people's ability to get care. We think of those as social determinants or structural deficits barriers for people getting the care that they need to stay healthy or slow and manage the progression of chronic disease or fill gaps in care. So the marketing team should be thinking about what data sets do we have that can contribute to this and helping build that in.
And then the third thing is working with the clinicians, like Dr. Cardoso, to talk about how best do we tell this story inside the organization and outside. At the end of the day, a lot of population health is about identifying needs and helping people change behavior. That's what we do in marketing. It's really getting involved, contributing to the data effort and then putting it all together in a way that is compelling for individuals and clinicians to change behaviors.
Bill Klaproth: I love that line, Mike. You are not on the sidelines when it comes to public health and that marketers have the ability then to take this information and change those attitudes and behaviors. So when it comes to the actual tools of marketing, you were talking about storytelling, so then a marketing director could put together a campaign encompassing the website, social media, direct mail, all those tools that marketing directors have at their disposal, is that right?
Mike Eaton: Absolutely. It's doing so in a way that it understands how people want to consume information. We know today that 97% of people have a cell phone. There's all sorts of ways. A high percentage have smartphones that we can push information to people. Prompts for them to not only access medical care, but to think about their own healthy behaviors.
There's all manner of ways that we can tell stories in communities so people can understand the importance of this, whether it's thinking about access to healthy food and healthy food Choices. safe places to have recreation and play and walk and all of that. Any number of different dynamics, dynamics in the home, dynamics in the neighborhood, in the schools. The marketing team really can play a great role in helping build awareness, get people engaged and help give them the encouragement and the tools to change behaviors.
Bill Klaproth: Right. And then when that is all said and done, how do we measure success of these types of health initiatives?
Mike Eaton: Well, I go back to Adam and Dr. Cardoso because Dr. Cardoso was looking at overall health status for our population. So we should see fewer emergency department visits, unnecessary ED visits. We should see fewer hospitalizations. There should be a healthier community in terms of looking at diabetes and heart conditions and, ultimately, people's well-being. It goes back not just to my physical health, but my emotional, social, physical, spiritual and family economic well-being. We should be able to see improvements in all of those dimensions. And someone like Adam plays a key role in helping us track that and measure that, manage that because at the end of the day, if it's not changing, then we need a new strategy.
Bill Klaproth: So it's kind of like a circle then as you implement these strategies and changes and build marketing campaigns, it kind of reverts back to Adam to go, "Is this working? Are we seeing less hypertension now? Are we seeing less diabetes?" Is that kind of right? It's kind of like a big circle?
Mike Eaton: To use Adam's fishing analogy, if he's casting his nets and we're coming up with less type 2 diabetes than we were when we started, then we've made progress.
Bill Klaproth: Yeah, I love that. That is great. And if there are any fishermen who are marketing directors who are listening to this podcast, I'm sure they are really enjoying this. So as I talked about that circle and going back to you, Adam, let's get your final thoughts on this very important topic. Adam, how about your final thoughts?
Yeah. I think Mike's topic and conversation around how do you measure success, something that really stands out to me is that the relationship and the strength of the relationship that your healthcare network has with the patients within various areas and that measuring things like brand loyalty and brand recognition become really important when you start talking about how are you going to determine and drive improvements in population health. I think it's one of those undervalued and understated components of a population health strategy that marketers can really take to heart. They need to have a strong brand in order to grow and improve the health of communities that you're interacting with.
Yeah, that makes sense. Having a really strong brand loyalty and recognition to really enable you to do this work and really be successful in your population health strategy. That makes a lot of sense. And Dr. Cardoso, let's go to you. Let's get your final thoughts on this.
Dr. Megan Cardoso: Thank you. Yes. One of the things I was thinking about as Mike and Adam were talking, physicians struggle with treating our patients as customers. These are people, we treat their health, their well-being their mind, their body, their soul, right? And so when we think about them as customers, a lot of times physicians have this immediate rebuttal feeling.
On the flip side, what we do almost 100% of our day is change management. And so thinking about how we can partner with our marketing directors to say, "This is what you're great at, is change management. We're trying to do the same thing. How do we partner while we're taking care of our patients and their well-being with change management at the same time?" is such a powerful place to come from. And then when you tie that in to the population health, the data, and really tracking how you're doing, it's just an all-star team.
Bill Klaproth: Absolutely. You can see how all of those things tie in together and, if you do it right, how powerful that can be. Okay, Mike, your last to cast the line. Reel us in. Wrap this up for us as we end our podcast on population health strategies.
Mike Eaton: there's an old thing that people don't care what you know until they know that you care. And when we think about impacting the health of different communities, so if I think at a ZIP code level, and I think about. communities that may have language barriers or transportation barriers, may be a function of there's not enough resources in their area, we really have to be mindful that this isn't simply a matter of putting some programs together and offering some services. We have to engage in those communities. You have to demonstrate that you care about physical, emotional, social, spiritual health, economic well-being, for them to care what you know in terms of changing behaviors, teaching new ways to live healthy, to manage chronic disease.
So from a marketing standpoint, and really from an organizational standpoint, there has to be an authenticity, a genuineness to this in terms of getting engaged. And that's a really important component of success. So think it's just important to always operate in that context of we are part of the communities we're trying to serve and help people to heal.
Bill Klaproth: That is one of my favorite quotes of all time. People don't care what you know until they know that you care. That really sums it up. And as you said at the very end there, people want to know that you're part of the community. You're in there with them. So this is really, really important.
What a great podcast. Thank you all for your insights as we talk about population health neighborhoods and learning how a person's ZIP code can actually determine their health. So really interesting, great information.. Adam, Dr. Cardoso, Mike, thank you so much for your time. We really appreciate it.
Dr. Megan Cardoso: Thank you.
Mike Eaton: Thank you.
Adam Russman: Thank you.
Bill Klaproth: And once again, that's Adam Russman, Dr. Megan Cardoso and Mike Eaton. And this episode is sponsored by BVK, an independent business, marketing and advertising agency with expertise in delivering purpose-driven healthcare experiences that impact lives, build healthy communities and shift societal health behaviors just like we were talking about today.
Visit bvk.com/rapidinsights to schedule a private session with one of their health experts today. Once again, bvk.com/rapidinsights. And to learn more about SHSMD, you can visit shsmd.org. That's S-H-S-M-D dot org and visit our education page to learn about our upcoming programs. And if you found this podcast helpful and, quite seriously, how could you not really? How could you not? Please share it on all of your social channels and please hit the subscribe or follow button to get every episode. This has been a production of DoctorPodcasting. I'm Bill Klaproth. See ya!
Building Population Health Neighborhoods: Learn How a Person’s Zip Code Can Actually Determine Their Health
Intro: The following SHSMD podcast is a production of DoctorPodcasting.com.
Bill Klaproth: So do you know the health needs of the population you serve? And if so, are you developing services to meet those needs? Hmm. I ask you this question. Well, let's talk about building population health neighborhoods. This is a really important topic and learn how a person's ZIP code right in your community can actually determine their health, giving you valuable insight into their needs. So let's talk about it with Adam Russman, Director of Data and Analytics at Wellforce; Dr. Megan Cardoso, a Medical Director of Population Health at Wellforce; and Mike Eaton, Senior Vice President of BVK Health. And this episode is sponsored by BVK Health. So let's get into it right now.
This is the SHSMD podcast, rapid insights for healthcare strategy professionals in planning, business development, marketing, communications and public relations. I'm your host, Bill Klaproth. And in this episode, we talk about building population health neighborhoods, and learning how a person's ZIP code can actually determine their health with Adam Russman, Director of Data and Analytics at Wellforce; Dr. Megan Cardoso, a Medical Director of population Health at Wellforce; and Mike Eaton, Senior Vice President at BVK Health. And this episode is brought to you by BVK, an independent business marketing and advertising agency with expertise in delivering purpose-driven healthcare experiences that impact lives, build healthy communities and shift societal health behaviors. Visit them at bvk.com/rapidinsights to schedule a private session with one of their health experts today.
Dr. Cardoso, Adam and Mike, welcome to the SHSMD podcast. We start every episode of the SHSMD podcast with rapid insights. One quick tip someone can use to make their marketing communications better today. Mike, let's start with you. Give us your rapid insight
Mike Eaton: There's a really critical shift in how you should think about your strategies, you think about communicating to your customers. And it starts with changing the question. From asking "How are we doing?" to asking "How is my customer doing?" And customer may be an individual. It might be a family. It might be a segment of folks with a particular need. It can be a whole community. But if you start with understanding how your customer's doing, you'll often come up with different answers to the problems that they have or the unmet needs that they're trying to solve for.
Bill Klaproth: Love that. So switch that question to "How are you doing?" Thank you for that rapid insight, Mike. Adam, you're up next. Give us your rapid insight.
Adam Russman: ZIP code should only be five digits or nine digits. Nothing in between will work.
Bill Klaproth: Five digits or nine digits. Let's remember that, people. All right, Adam. Thank you for that rapid insight. I appreciate it. Dr. Cardoso, you are up next. Give us your rapid insight.
Dr. Megan Cardoso: When you're working with physicians and physicians offices on complex topics like building healthy communities, it's important to present all of your information in practical, simple, and effective ways.
Bill Klaproth: That is your rapid insight. Thank you, Dr. Cardoso, Adam and Mike. We appreciate that. Adam, we're going to go to you first as we talk about this great topic, building population health neighborhoods, and we can learn how a person's ZIP code can actually determine their health. So let me ask you this, Adam. Health systems are making the shift from looking for customers to buy the services they offer to developing services to meet population health needs. How does someone in your role help make that shift?
Adam Russman: One of the foundational elements to any health system is how they best leverage and use their data to meet the needs of both their community and the broader organization. The use of data within this context is really to drive insights that help define and generate most high value services that are needed within any type of marketplace. And when you started talking about healthcare, this becomes increasingly important, particularly around different types of clinical services and different types of interventions that you can then drive and drive from data.
So someone within my role is the person who is responsible for gathering, cleaning and preparing data for individuals like our clinicians and other administrators within the hospital systems to derive insights and define what their market plans should be going forward.
Bill Klaproth: You're kind of like a ZIP code hunter. So you're looking for certain things within a community like hypertension or diabetes or other things like that. You go out looking for those types of things?
Adam Russman: You can go out looking for those types of things or like a good metaphor, a good simile, is you act like a fishermen would. You're really trying to review where in the sea you may find activities and individuals. You're trying to cast the line and cast the net to identify those. So you can either use a model where you're hunting and you're trying to find where those are or you let the data speak to you by using some of the later technologies and newer activities to sort of read out what is happening underneath the sea.
Bill Klaproth: Right. So using the fishing metaphor at times. You're just casting the net wide to see what you catch and what turns up.
Adam Russman: Correct. It's not necessarily taking the idea that there must be hypertensives about there. It's looking around your network to say, "It looks like I have a hotspot of cardiac patients in this one geographic region on the south shore of Massachusetts who have certain utilization patterns based on their proximity to different types of services. And by sort of framing the question that way, as opposed to saying, "Tell me where my hypertensives are," you end up identifying more interesting patterns that can come from just naturally reading data.
Bill Klaproth: So then how would a marketer go about extracting this information from ZIP codes? I'm just curious. How do I look at a ZIP code? Where do I go to find out that, "Oh, my gosh, I see that this certain ZIP code has a high prevalence of hypertension." How do you do that as a marketer?
Adam Russman: Lots of people in the data world will know that the first thing you really need to do is get and acquire really clean data. The world has ZIP codes depending on what your systems are and what they look like. Luckily, things like EMR and practice management systems have improved data capture, but you really need to hone in and isolate and get a working ZIP code for an individual patient within your population. And then in using that, you need to then go through a whole exercise of taking those ZIP codes, mapping them in, identifying what towns and what activities get associated to those and then you're tying it into all of your other clinical data that you gather, your quality measures, your clinical activities from your EMR and your claims-based measures to come up with an overarching view and picture of what your population would look like.
Bill Klaproth: Yeah, that is really interesting. I love that data perspective you bring to that. You're mining the ZIP codes to see basically what you can find. So then, as you find some areas of interest or things that are important to you, let me ask you this, Dr. Cardoso, from a physician's point-of-view, what are some of the most stubborn barriers then once you find this information out to building healthy communities?
Dr. Megan Cardoso: That's a great point. I'm actually going to take you a step back there for a second. One of the biggest challenges we have is getting the demographic information that we need. So we may know what people's ZIP codes are, but we don't know what language they speak or what ethnicity they have or where they're coming from.
And as, you know, with COVID and the pandemic, inequities in healthcare have just become so much more prevalent and we've been able to see them more. And so how do you specify and target specific communities based on all those factors? Well, the problem is that a lot of our offices and our PCPs and our hospitals aren't equipped or prepared to ask those questions yet. So I would say to take a step back, I think we need that clean data and really working with our providers and our offices and our hospitals to feel comfortable asking that question and explaining why it's so necessary and relevant.
Bill Klaproth: Yeah, thank you for bringing that up. That's really important. And I'm glad that you said that because, as you're talking about barriers, that seems like one of the ones you first have to overcome. What other stubborn barriers would physicians face?
Dr. Megan Cardoso: Yeah. So pervasive problems like mental health are very big. We find people who have a lot of chronic conditions often also have something like depression or anxiety that go along with it. Sometimes it's identified, sometimes it's not. But we know that people who have depressive disorders for example are utilizing more often.
There's lack of access to healthy food for diabetics. There's lack of good family and social supports for people. And as we think about transitioning most of our healthcare from the hospital, which has always kind of been the hub of our healthcare, as we're transitioning that to more "How do we take care of people in their homes, in their communities?", it's important to think about how do we get the resources we need to take care of them into those homes and into those communities.
Bill Klaproth: Yeah, that's a really good point about that transition again from the hospital to care in the home or the community. So can you give us an example of all this, kind of a real world look at how this works?
Dr. Megan Cardoso: Sure. A team of physicians came together and said, "What are one of these barriers that is preventing equitable care that we want to tackle first?" And so we, as a group, came together and said, "Depression is something that is pervasive in our community. It crosses all socioeconomic ZIP codes, et cetera." And so we thought about depression and we built out a playbook for our physicians and our offices.
It really thinks about a couple of things. So one is how do you standardize screening across the board, all ages, all demographics, all languages to identify depression? And then once you have identified depression, what do you do? What's the next step? How do you integrate behavioral health into primary care in p laces where resources are low? So we have built out a playbook for our physicians, that's just kind of a step-by-step, "This is how you screen. This is how you refer someone to the program. This is the followup. This is how we gather data. Here's some resources for your patients. Here's some prescribing guidelines." So again, very simple polished guidelines that are easy and quick reads for our patients.
Bill Klaproth: And generally, are physicians receptive to this information?
Dr. Megan Cardoso: Very receptive. Everyone in busy clinicians offices, we don't have a lot of time to spend with all of our patients going through all of this. So, with standardized screening and then teams that can help us with our depressed patients, people have been very receptive to this.
Bill Klaproth: Wow. That's really good to hear. So Adam has kind of went and found the information we need. Dr. Cardoso has put together a playbook for the physicians. Mike, how do we put this together from a marketing role? How do you see marketing playing a role in population health strategy and activation?
Mike Eaton: I think marketing has a really big role to play in population health. And one of the concerns that I have often is that marketers don't see that. So there's a sense that that happens someplace else. There's a couple of things that are really critical. One is in marketing. A core function that marketers play is identifying needs, unmet needs, where there's opportunities, gaps in the communities that we serve and the populations we serve them in our customer base.
So as Adam talked about those data tools, and as Dr. Cardoso talked about the importance of having not just ZIP codes, but also demographic data, understanding language, understanding a whole series of variables that impact how people make healthcare decisions. We know there are a lot of databases that marketing has access to be able to fill in some of that qualitative insight and data, as opposed to just the quantitative of who lives here and some basic demographics. So marketing has a big role to play there.
Second area marketing has a big role to play is when we think about how the story gets told. And Dr. Cardosa was referencing that, that it's important not simply to take a really complex topic like this and drop it on physician practices that are busy. They're already managing lots of data. They have a lot of information that flows through their practices. But how can we put it together in a way to tell stories?
We know that storytelling has helped people learn. We know that if we can bundle these things up in playbooks and tool kits and different types of things that are really well done, polished, simple, clean, taking the complex, making it simple, we have a much higher likelihood of people actually putting those things to use. And that's what creates the impact in the communities. It's taking the work that Adam does to identify where there are opportunities for us to intervene, the work that Dr. Cardoso does to design highly effective interventions, and then that role of marketing can help to plate, to take that information and put it out there in a way people can use it.
Bill Klaproth: So for a marketer listening to this, what is the first step in doing what you just said, having that information at your fingertips, your hands, if you will, and then, "Okay, I've got this information. What do I do first?" I know you talked about storytelling, but kind of give us a roadmap for a marketing director. What should that person do with this info?
Mike Eaton: Well, the first thing is to not presume that you're on the sidelines when it comes to population health. So it's to make that commitment to plug in to population health development efforts, developing strategies in particular markets and regions and thinking about how to communicate, how to change people's behaviors. And that's an important first step, is to know that you're relevant to the process.
The second is, as Adam talked about, it's understanding what data do we have, where do we have gaps in our data to be able to identify the things that Dr. Cardoso also spoke of in terms of kind of the qualitative variables which influence people's ability to get care. We think of those as social determinants or structural deficits barriers for people getting the care that they need to stay healthy or slow and manage the progression of chronic disease or fill gaps in care. So the marketing team should be thinking about what data sets do we have that can contribute to this and helping build that in.
And then the third thing is working with the clinicians, like Dr. Cardoso, to talk about how best do we tell this story inside the organization and outside. At the end of the day, a lot of population health is about identifying needs and helping people change behavior. That's what we do in marketing. It's really getting involved, contributing to the data effort and then putting it all together in a way that is compelling for individuals and clinicians to change behaviors.
Bill Klaproth: I love that line, Mike. You are not on the sidelines when it comes to public health and that marketers have the ability then to take this information and change those attitudes and behaviors. So when it comes to the actual tools of marketing, you were talking about storytelling, so then a marketing director could put together a campaign encompassing the website, social media, direct mail, all those tools that marketing directors have at their disposal, is that right?
Mike Eaton: Absolutely. It's doing so in a way that it understands how people want to consume information. We know today that 97% of people have a cell phone. There's all sorts of ways. A high percentage have smartphones that we can push information to people. Prompts for them to not only access medical care, but to think about their own healthy behaviors.
There's all manner of ways that we can tell stories in communities so people can understand the importance of this, whether it's thinking about access to healthy food and healthy food Choices. safe places to have recreation and play and walk and all of that. Any number of different dynamics, dynamics in the home, dynamics in the neighborhood, in the schools. The marketing team really can play a great role in helping build awareness, get people engaged and help give them the encouragement and the tools to change behaviors.
Bill Klaproth: Right. And then when that is all said and done, how do we measure success of these types of health initiatives?
Mike Eaton: Well, I go back to Adam and Dr. Cardoso because Dr. Cardoso was looking at overall health status for our population. So we should see fewer emergency department visits, unnecessary ED visits. We should see fewer hospitalizations. There should be a healthier community in terms of looking at diabetes and heart conditions and, ultimately, people's well-being. It goes back not just to my physical health, but my emotional, social, physical, spiritual and family economic well-being. We should be able to see improvements in all of those dimensions. And someone like Adam plays a key role in helping us track that and measure that, manage that because at the end of the day, if it's not changing, then we need a new strategy.
Bill Klaproth: So it's kind of like a circle then as you implement these strategies and changes and build marketing campaigns, it kind of reverts back to Adam to go, "Is this working? Are we seeing less hypertension now? Are we seeing less diabetes?" Is that kind of right? It's kind of like a big circle?
Mike Eaton: To use Adam's fishing analogy, if he's casting his nets and we're coming up with less type 2 diabetes than we were when we started, then we've made progress.
Bill Klaproth: Yeah, I love that. That is great. And if there are any fishermen who are marketing directors who are listening to this podcast, I'm sure they are really enjoying this. So as I talked about that circle and going back to you, Adam, let's get your final thoughts on this very important topic. Adam, how about your final thoughts?
Yeah. I think Mike's topic and conversation around how do you measure success, something that really stands out to me is that the relationship and the strength of the relationship that your healthcare network has with the patients within various areas and that measuring things like brand loyalty and brand recognition become really important when you start talking about how are you going to determine and drive improvements in population health. I think it's one of those undervalued and understated components of a population health strategy that marketers can really take to heart. They need to have a strong brand in order to grow and improve the health of communities that you're interacting with.
Yeah, that makes sense. Having a really strong brand loyalty and recognition to really enable you to do this work and really be successful in your population health strategy. That makes a lot of sense. And Dr. Cardoso, let's go to you. Let's get your final thoughts on this.
Dr. Megan Cardoso: Thank you. Yes. One of the things I was thinking about as Mike and Adam were talking, physicians struggle with treating our patients as customers. These are people, we treat their health, their well-being their mind, their body, their soul, right? And so when we think about them as customers, a lot of times physicians have this immediate rebuttal feeling.
On the flip side, what we do almost 100% of our day is change management. And so thinking about how we can partner with our marketing directors to say, "This is what you're great at, is change management. We're trying to do the same thing. How do we partner while we're taking care of our patients and their well-being with change management at the same time?" is such a powerful place to come from. And then when you tie that in to the population health, the data, and really tracking how you're doing, it's just an all-star team.
Bill Klaproth: Absolutely. You can see how all of those things tie in together and, if you do it right, how powerful that can be. Okay, Mike, your last to cast the line. Reel us in. Wrap this up for us as we end our podcast on population health strategies.
Mike Eaton: there's an old thing that people don't care what you know until they know that you care. And when we think about impacting the health of different communities, so if I think at a ZIP code level, and I think about. communities that may have language barriers or transportation barriers, may be a function of there's not enough resources in their area, we really have to be mindful that this isn't simply a matter of putting some programs together and offering some services. We have to engage in those communities. You have to demonstrate that you care about physical, emotional, social, spiritual health, economic well-being, for them to care what you know in terms of changing behaviors, teaching new ways to live healthy, to manage chronic disease.
So from a marketing standpoint, and really from an organizational standpoint, there has to be an authenticity, a genuineness to this in terms of getting engaged. And that's a really important component of success. So think it's just important to always operate in that context of we are part of the communities we're trying to serve and help people to heal.
Bill Klaproth: That is one of my favorite quotes of all time. People don't care what you know until they know that you care. That really sums it up. And as you said at the very end there, people want to know that you're part of the community. You're in there with them. So this is really, really important.
What a great podcast. Thank you all for your insights as we talk about population health neighborhoods and learning how a person's ZIP code can actually determine their health. So really interesting, great information.. Adam, Dr. Cardoso, Mike, thank you so much for your time. We really appreciate it.
Dr. Megan Cardoso: Thank you.
Mike Eaton: Thank you.
Adam Russman: Thank you.
Bill Klaproth: And once again, that's Adam Russman, Dr. Megan Cardoso and Mike Eaton. And this episode is sponsored by BVK, an independent business, marketing and advertising agency with expertise in delivering purpose-driven healthcare experiences that impact lives, build healthy communities and shift societal health behaviors just like we were talking about today.
Visit bvk.com/rapidinsights to schedule a private session with one of their health experts today. Once again, bvk.com/rapidinsights. And to learn more about SHSMD, you can visit shsmd.org. That's S-H-S-M-D dot org and visit our education page to learn about our upcoming programs. And if you found this podcast helpful and, quite seriously, how could you not really? How could you not? Please share it on all of your social channels and please hit the subscribe or follow button to get every episode. This has been a production of DoctorPodcasting. I'm Bill Klaproth. See ya!