One-in-five rising-risk patients escalate into the high-risk group every year. To prevent such escalation, successful population health managers provide care management support—but doing that at scale is better said than done for many. After all, we're talking about ~30% of the population.
To build a sustainable population health enterprise, provider organizations must deploy every piece of the care management enterprise effectively and efficiently. Working with community partners or volunteers can help to scale resources to manage populations over time, and engage them outside a hospital's four walls.
Postal workers monitor at-risk patients long-term at low cost
An innovative way to scalable monitoring of at-risk patients comes out of States of Jersey. After the Jersey postal service ran a competition asking employees what other services they could potentially provide, they decided on a "Call and Check" program that would train postal workers to check on at-risk residents while delivering their mail.
For a cost of $6 to $8 per person, the postal workers visit frail and elderly patients twice each week-for less than five minutes each visit. They deliver prescriptions and provide appointment reminders, while also checking on patients to look for warning signs of deterioration.
Home care support delays need for costly nursery home care
Call and Check has grown since its inception. Not only has the program been scaled up to serve the entire island of Jersey, but the service offering is expanding. Postmen will soon begin offering day-to-day support for home care (e.g., cooking, grocery shopping, laundry, general home maintenance) to delay patients' admissions into costly nursery homes. Jersey Post is also engineering an electronic platform built into the postal workers' handsets to send messages to local health care providers.
The main message here is not to work with postal workers, but that provider organizations should think creatively about potential community partners to scale population health efforts and prevent avoidable and costly health care of at-risk patients.