New Population Health tool helps us keep our patients healthy

PPMM health center care teams will soon be able to discover with just a few clicks at a computer how to target treatment of specific health issues that affect patients of a particular age in certain communities – maybe even before these patients know they are facing a health challenge.

Thanks to an analytical tool called NextGen Population Health, which allows providers to quickly view and assess many aspects of population health targeted specifically for our patients, PPMM providers will be able to collect crucial health data based on where patients live, their age, their most recent infection-screening, and other indicators that may put them in risk groups for threats to their health.

“The population health analytical tool is an amazingly efficient way to find out immediately how our patients are doing,” said PPMM Chief Medical Officer Dr. Laura Dalton. “Based on the information we collect, we can do studies on health trends of patient groups, we can do targeted outreach to them about specific risks, and we can close care-gaps, such as making sure we see patients whose breast cancer-screening is overdue.”

PPMM acquired the tool just before the pandemic hit. Dr. Dalton has been supervising several months of testing, establishing policies and procedures within the organization, before rolling it out this spring.

Using Population Health to monitor and possibly anticipate barriers to the well-being of our patients is another way that PPMM is continuing to be at the forefront of preventive health care – something our patients count on PPMM to do for our community.

For example, the tool can identify patients in one area who have uncontrolled diabetes and use its geo-mapping capability to find and “layer in” other social determinants of health including access to transportation to pick up medication and access to local food markets. This allows our care teams to focus interventions such as enrolling patients into home-delivery medication programs and discussing with them ways to eat a more balanced diet if they are living in a “food desert.” 

Having this information also means care teams, the frontline workers that your gifts support, can alert PPMM’s advocacy team and our community partners about these issues, especially if we see high rates of uncontrolled diabetes or other potentially related health complications. 

If the tool shows that many patients in one region live in a county that has steep increases in rates of syphilis or that a local public health official reports an increase in sex trafficking, PPMM could launch an outreach campaign urging people to come in for STI testing and treatment or an education campaign about the prevalence of local sex trafficking and ways for young people to protect themselves.

“Having the population health tool is crucial to helping us make data-driven decisions about how best to keep our patients healthy,” Dr. Dalton said. “We know what the health challenges are, and we know how to treat them. This is a way to take the best care of our patients and be on the leading edge of this care.”