Patient engagement is critical as we move toward population health—as patients who engage in their own care by following medical recommendations and making healthy nutrition and lifestyle choices will have better outcomes and experiences. There isn’t, however, a clear path to successful patient engagement. Fortunately, public health can lend several established principles that may help us better involve patients in their own care: Using systematic, population-level solutions that require less individual effort. Engaging patients on interpersonal and community levels as well as personal. Identifying root-cause, assessing and capitalizing on strengths, and engaging stakeholders. Using strategies from behavioral economics to help individuals make good choices. Anticipating failure and learning from it.

1. Improve Patient Engagement with
Five Public Health-Inspired Principles
̶̶ Marie Dunn & Maggie O'Keefe

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The Issue of Patient Engagement
As the payment landscape evolves and financial
responsibility for outcomes shifts to provider
organizations, getting patients to make good
choices where it comes to their health is a
population health imperative.
The fiscal importance of this work is critical.
Even the “seemingly simple” step of
taking medication is a huge societal
challenge, with non-adherence
costing $300 billion annually.

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The Issue of Patient Engagement
As we move away from episodic payment,
we’re not just encouraging patients to take
medications and follow discharge instructions,
but insisting they exercise, eat better, and
smoke less.
How many times have you heard a clinician
ask, “How can I be responsible for outcomes
when I have no way to control what my patient
does at home?”

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A Better Approach to Patient Engagement
Avoid Asking Patients to Do Too Much
Too many patient engagement initiatives start
with the premise that we need to find
strategies to get patients to do more; we
believe this approach is deeply flawed.
If we look to the field of public health, which
has long managed populations of patients, the
most effective strategies to improve population
health pair behavior change with systematic
interventions.

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A Better Approach to Patient Engagement
Avoid Asking Patients to Do Too Much
For example:
While reductions in motor vehicle fatalities
are partially due to improved seat belt
usage, systematic changes outside the
individual’s control, like safer vehicles and
roadways, played a larger role.
From this point of view, population health
managers face a dual challenge: improving
strategies for engaging individuals in
behavior change, while systematically
preventing illness at the population level.

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A Better Approach to Patient Engagement
A Population-Focused Approach
Public health teaches us that systematic,
population-focused efforts are often more
effective than those that target individuals.
To underscore the importance of systematic
interventions, consider cholera.
Initially, medical opinion concurred with the
public: The disease was a judgment from
God and those who were “intemperate,
imprudent and filthy were predisposed to
this most dreadful disease.”

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A Better Approach to Patient Engagement
A Population-Focused Approach
Later, the medical community came to accept
that filth caused cholera and asked individuals
to do their part: Clean yourselves, clean your
homes, and clean often.
This was also not very effective.
It’s easy to see in retrospect that these are
hard problems to tackle without clean water
and sanitation infrastructure available
In other words, systematic, population-
focused interventions.

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A Better Approach to Patient Engagement
A Population-Focused Approach
We rarely compare cholera to chronic conditions
like diabetes and heart failure. But when we look
at those impacted, there are striking parallels.
Chronic conditions—a big driver of healthcare
spending and a focus in risk-based contracts—
disproportionately impact poor minorities who
live in the least-desirable areas of major cities.
Income is a significant predictor of health:
Impoverished adults die almost a decade earlier
than individuals with incomes four times the
federal poverty level ($11K annually).

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A Better Approach to Patient Engagement
What We Can Apply from Public Health
Start with public health concepts and ask the
question: Which of these are financially viable
in today’s payment environment?
In a fee-for-service environment, public
health and healthcare managers typically
had different fundamental goals.
With public health thinking about patients
over decades, and healthcare organizations
focused on one acute episode or ambulatory
visit, there was little opportunity to share
strategies between the fields.

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A Better Approach to Patient Engagement
What We Can Apply from Public Health
However, the advent of new payment models
that make health systems responsible for
populations of patients over much longer
timeframes realigns these fields.
Instead of asking how to improve our current
patient engagement strategies that were
developed in a tradition of treating illness, we
should instead be asking which of public
health’s strategies are fiscally viable today?

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A Better Approach to Patient Engagement
Five public health-inspired patient engagement principles:
Consider these guiding principles as you develop patient engagement
strategy and vet focused interventions:
1: Look for systematic, population-level solutions that require less individual effort.
2: Develop a multi-faceted approach to engage patients-individually and community wide.
3: Identify root-cause, assess and capitalize on strengths, and engage stakeholders
4: Use strategies from behavioral economics to help individuals make good choices
5: Anticipate failure and learn from it

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A Better Approach to Patient Engagement
1: Look for systematic, population-level solutions
that require less individual effort.
Taking a page from public health’s Health
Impact Pyramid, consider strategies for
population level in addition to focusing
on individuals?
Population level strategies often bring the
benefit of requiring less individual effort.
Adding a park to a neighborhood might get
a community outside and exercising more.

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A Better Approach to Patient Engagement
2: Develop a multi-faceted approach to engage patients-
individually and community wide
The socio-ecologic model teaches us that
hitting a problem from all angles is likely to be
far more effective than just addressing one.
Successes in smoking cessation came not
just from individual education alone but
strategies like taxes, restaurant bans, and
public campaigns that make it not only harder
to smoke, but less socially acceptable.

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A Better Approach to Patient Engagement
3: Identify root-cause, assess and capitalize on
strengths, and engage stakeholders
Make sure you understand the root cause
of the problem for both individual and
community wide intervention.
Asking someone to weigh themselves daily
when they can’t stand steadily on a
scale becomes an impossible task.
Create opportunities to engage
patients to provide feedback at
the individual level.

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A Better Approach to Patient Engagement
4: Use strategies from behavioral economics to help individuals
make good choices
Behavioral economics shows that
individuals struggle to make good choices.
For example, we struggle to weigh costs
and benefits that are separated across
time, such as a cigarette today versus
lung cancer decades from now.
Industries like tobacco and junk food make
a lot of money by exploiting this fact.

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A Better Approach to Patient Engagement
5: Anticipate failure and learn from it
Data and a quality improvement mindset
are key. Knowing there is no one-size-fits-
all approach, build an infrastructure that
anticipates failure.
How to use data to measure baselines and
monitor success so you can recognize and
scale successes and abandon programs
that don’t work?
The quality improvement mindset of plan,
do, study, act is highly relevant to this work.

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Analytics Are Critical to Patient Engagement
Analytics should play a key role in helping
you to not only prioritize key focus areas,
but to assess return on investment, help
guide improvements, and make the
financial case for this work.
A well-considered patient engagement
strategy uses data to ensure efforts
are focused on solutions that employ
interventions with the greatest bang for
the buck.

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Analytics Are Critical to Patient Engagement
Have you identified the populations that
require the most support and engagement?
Have you assessed your interventions to
determine if they’re financially viable?
What’s the likely return on your investment
and in what timeframe?
Can you use data to build the case
for getting paid for that service?
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Aim for Less Individual Effort
Always consider opportunities to employ
population-focused or systematic interventions
that require less individual effort.
Think of the patient’s mindshare for
engagement as a highly valuable but limited
resource; use it wisely.
While we have a tremendous amount to learn
viable population health strategies, we save
ourselves a lot of heartache if we stand on the
shoulders of giants in the field of public health
as we build these new competencies.

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For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

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More about this topic
Link to original article for a more in-depth discussion.
Improve Patient Engagement with Five Public Health-Inspired Principles
Quality Data Is Essential for Doctors Concerned with Patient Engagement
Dr. Ed Corbett, Deputy CMO
From Care Management to Population Health Management
Brent Dover, President
Population Health Management: One Example That Shows Why It Really Matters
Kathleen Merkley, DNP, APRN, Sr. VP Clinical Improvement Line
What is Population Health and How Does it Compare to Public Health?
Leslie Hough Falk, Customer Engagement, VP
Population Health in Three Paragraphs
Dale Sanders, Executive VP of Software

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Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
Marie Dunn joined Health Catalyst in September 2014. Prior to Health Catalyst, Marie
worked for The Advisory Board Company in Washington, DC. Marie completed her
undergraduate work at the University of Virginia and graduate work at Harvard School of
Public Health.
Maggie O'keefe joined Health Catalyst in July 2015 as Associate Director, Accountable
Care. Prior to coming to Health Catalyst, she worked for CCNC Services as a Clinical Data
Analyst. Maggie has a Master’s degree in Social and Behavioral Sciences from the Harvard
School of Public Health and a Bachelor’s degree in Religious Studies from Yale University.