This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.

Today we have another interview in action from the conferences that just happened down here in Miami and Orlando. My name is bill Russell. I'm a former CIO for a 16 hospital system and creator of this week health, a set of channels dedicated to keeping health it staff current and engaged. We want to thank our show sponsors who are investing in developing the next generation of health leaders, Gordian dynamics, Quill health tau site nuance, Canaan, medical, and current health.

Check them out at this week. health.com/today. Here we go. Here we are at HIMS 2022, and we are here with director of population health analytics for spectrum health. , can you introduce yourself?

Yeah. My name is Maha Salahuddin, the director of population health, data and analytics at spectrum health. we are a large 14 hospital, , unit in west Michigan and we are working on acquiring another large hospital health system, currently a 14 hospital system soon to join with Beaumont health as well. And do all things, population health, data, and analytics, , focusing on specific patient populations, using a lot of that data light being data that we have Create provider scorecards, , KPI dashboard for executives, , and really help the population of the west Michigan area.

So Western Michigan, by the way, we have him setting up in full force behind us. So it's going to look a little bit of a noise behind us, the Western Michigan population. Give us an idea of what that does that is that.Sort of a U S population. Do you have some, some urban, some rural,

some it's a lot of rural, , definitely some urban, just because of grand rapids being, being a college town, you do have that. , but it is very different from the Southeast side of the state. , demographics are a little bit different and also just the prevalence of certain chronic conditions that we would see.

So population, do you guys, do you guys have a, your, your, , you have managed care lives at risk lives and those kinds of things.

So my department in particular, we focus on our at-risk lives, , or, , about almost a quarter million at risk lives, mix of ACO, Medicaid, Medicare, and commercial care, Medicaid and commercial.

Yeah. Okay. So that covers the gambit there as well. , you know, when, when I talk to people around population health, some of the challenges become, , getting people to engage in their own health. How are you using the data? To get people to engage in their own home. Yeah.

So we use a lot of the data to help identify vulnerable populations, , or even just populations like the young and healthy adults.

Right. How can they better interact with the spectrum? Don't have primary care physicians don't want to come into the office with like virtual health. , so a lot of the data that we utilize is to really segment the population into different cohorts and then think about, you know, what are the straps. To engage with that population for certain populations like Medicare and Medicaid, that might mean they need to work with a community health worker, a social worker here manager, , for other folks, , like the young and healthy, it might mean that, you know, we have to think about how do we connect with them from a digital platform.

, so HIMS being the first. As to kind of think about how to do that. , but our department really looks at what are those different cohorts and kind of, what, what will that engagement look like? What kind of data are you bringing in? You know, we talked about the whole, and we've talked about this a lot on the show about the whole patient profile.

The more we know about people, the better we can care for that.

Yeah, we're using both claims and clinical, so EHR data. , and so we try to paint kind of that full picture of the patient what's happening right at the point of care. But what's also happening from claims. If the patient's out of state, you know, we're going to get that information. and so a lot of the programs that we do, like I mentioned are towards those frequent utilizers. Populations patients with ambulatory care, sensitive conditions, CHF, COPD, diabetes, hypertension, , who are also overly utilizing the healthcare system. So kind of using that hospital doors, a revolving door, , to a lot of, , information just to kind of help our care managers and the people who are at the point of care, being able to see what's happening, even when that patient's not in our line of sight.

you know, it's, it's interesting. There's a, there's a whole population that we struggle with and I've talked to some CEOs and others this week about, , the, the underserved. And you mentioned that earlier, , specifically the homeless population, you know, from a digital standpoint, , do we see them well? I mean, can we get enough information on them to care for them?

Well, yeah. So it's funny, you mentioned that we actually had a pilot that we started with one of our community organizations, , to look at housing for some of these frequent, , utilizers who happen to be homeless. And so we did a pilot with a clinic that is primarily Medicaid and we worked with our health plan to, , essentially secure housing for these patients. And what we've seen as a result of that is fewer ed visits. Right? You're not going to the EDS frequently, , better just management of chronic diseases, because they're now connected to a care manager or a behavioral health worker who is able to assess any outstanding needs that they have.

, you know, they help with transportation. So if the patient does need to go to a PCP appointment, you know, they have some sort of way to get their. And so definitely a big opportunity in the area that we're in. And the pilot that we started is, , relatively small. Cause it's just one clinic, but we've seen really good success.

So we're looking forward to kind of rolling that out. Is there a good flow of information from those partner organizations? Cause you mentioned a bunch of organizations that probably are not with.

Yeah, there is. I mean, , our EHR is a big source, so a lot of those, , organizations, especially they're the clinical folks, right.

They can access some of that information just through our community connect partners. , but I think we could definitely do better, , in terms of getting that information out to our community organization,

the, , when we talk about using the data, what's, what's the potential what's, I mean, what are you looking at down the road and say, man, I. This is where we would like to go. And I don't know if this partnership, our partnership, this merger of two healthy. Does that help to expand

some of these things? Yeah, I think the big is proactive. , so we're pretty early on our value journey. , a lot of what we do right now is using. Clinical data, which is typically reactive, right.

Patient comes into the ed and then yes. Yeah.

So, , what we're hoping to do is be proactive. If we know that, you know, patients who have CHF, COPD, , some of these chronic conditions, they're going to be exacerbated in the next two, two years. We want to do stuff now to make sure that we're combating their inpatient and ed utilization.

We're getting them the reason. They need to better manage their health. So I think for our health system, it's really going to be that proactive monitoring who are the patients that are not on our radar now, and really don't need to be necessarily, but in two years, they're going to be the high utilizers

with the nursing shortage and staffing, shortage, and pressure there is, are there things you're looking at there as well, different models?

Yeah, definitely. I mean, anywhere, any place we can use leverage technology, right? So we think of transitions of care. So when a patient is discharged from the ed or an inpatient setting, you know, the old workflow would be that a care manager would call the patient for that TOC call. , we're now leveraging technology to do that.

So there's a chat bot that, , engages with the patient and assesses, you know, How was your discharge planning? Do you have any questions? Would you like to communicate with C H CHW or a community? , , , case manager. And then if that patient says, yes, I'd like to speak to an actual person, we'll route the call to that department, but, , it's been really effective.

We've seen, you know, just using technology in that way. We've seen a reduction in ed utilization.

Are there datasets, you wish you had. that's a good question. , I always think SDOH is one area that we can do better. , I think the documentation is not great for, for folks who have, , mental health illnesses.

so that's one area that I think we can kind of beef up our, our data that we capture. , but outside of that, I think we're, you know, we're at a much better place than we were a couple of years ago.

We had, we had groups of our population. I was in Southern Cal. And so we had a significant, , undocumented population.

They didn't want to be known. So every time they came in, it was a different social security number. Actually. It was a different name. Yeah. , we actually had some pretty sophisticated ways to sort of pieces together. 'cause we were just trying to do from a care standpoint, that continuity of care. But do you have similar challenges or is Michigan a little bit shielded from that kind of we're a little bit shielded, I would say from, from that, but I do think, you know, we have to be creative about how, how do we connect data elements that are coming in.

The member ID is not the same, right. From the different data sources. , we do a pretty good job in terms of being able to match those records up. , light beam actually has a really good patient matching tool. So they'll think about things like, you know, patient's gender date of birth address, right. And kind of use those factors to paint the picture of, yes, this is the same person.

Let's talk about the young invincibles. Yeah. You're you have the, , the college age students. Is there anything specific we're doing around that population? I'm going to get them to engage in their health earlier.

Yeah. Virtual health is big. , preventive health is as big, right? So just making sure, I mean, you might be young and healthy, but you still need to get your vaccinations.

You need to still come in for your annual physical, get your blood work done. There's a reason we call them the young invincibles. That's how they think.

But, , but yeah, I mean, I would say preventive is really big and then virtual, what we've seen, especially with COVID and is that, you know, folks want to do telehealth and it works and they don't have to spend 20, 30 minutes driving back and forth to the doctor's office sitting in a waiting room.

so tele-health, I think is really the way forward for that population. And we're fully leveraging that wherever we can. , I mean, even outside of just our young and healthy population where we're hoping to move towards more telehealth altogether, does spectrum have, , mental wellness services, digital? we, yeah, you can do like online therapy and you can meet with like a psych psychiatrist, psychologist online or through telehealth. , but I do think that's another area where we could probably

expand, what are you talking about? Population health. The unseen thing that's going on. And, , you know, with isolation as we come through the pandemic, I just know it, it almost doesn't matter what age group, cause we've also seen the, , , the suicide rates, the overdoses and whatnot could go up as well.

That's the reason I asked about that. It's it. It's interesting. When you say population health, it covers such a broad area. It used to be so hard to define it, like population health. What's that, what does that mean? But it sounds like we have a lot more focus we're using the data to really help that population to live healthier lives.

Yeah, for sure. Yeah. I mean, I think for us, especially because our, , Medicare population, right. We know, we know kind of what are the main areas that we need to focus to bring those. , I will say commercial group or commercial younger, healthier folks. , it's a little harder because again, they're, they're not going for, , some of those chronic conditions, right.

They might be going a one-off because they have a surgery or they have, , you know, they had a fall or a fracture, so. And that group is a little bit tougher. , but I think that's an area for us to kind of continue working on.

Thank you for your time. I hope you have a, have a great show, at least post check.

It sounds like your checking process has been a little challenging.

I'm gonna check in right after here. Fantastic. Thank you.

Thank you. Another great interview. I want to thank everybody who spent time with us at the conferences. It is phenomenal that you shared your wisdom and your experience with the community, and it is greatly appreciated.

We also want to thank our channel sponsors who are investing in our mission to develop the next generation of health leaders, Gordian dynamics, Quill health tau site nuance, Canon medical, and current health. Check them out at this week. health.com/today. Thanks for listening. That's all for now.