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It was no great leap for Austin Regional Clinic to embrace the concept of population health, an approach that aims to improve the health of groups of people, particularly those with more medically complex conditions. Our medical group was founded on those principles back in 1980, when no one ever heard of the term. Over time, we became very good at population health and now we are often asked to present our “best practices.”

What’s the secret to our success? The long answer often includes a description of our IT investments. No doubt the advent of electronic medical records has made us better — instead of reacting to illness, we are beginning to use the data to predict illness, allowing us to shift resources to the sickest patients.

But it is the human element — the way each provider engages with the patient — that takes us from simply identifying the high-risk to making a difference in their lives. The technique we’ve honed is motivational interviewing.

Listen Versus Fix

The “front line” of our population health program is our nurse navigation team. Ten years ago, it consisted of four trained nurse navigators who primarily guided our Medical Home patients — individuals living with chronic conditions who rely on frequent care from various specialists. Today, this team has grown to 25 and now includes in-hospital nurse navigation as well as a Home Health Navigator.

While the roles within our team have expanded, our approach to patient interaction has not. Instead of telling our patients, we ask questions. We hire listeners, not fixers.

To a psychologist, motivational interviewing is a fundamental technique. It is less well known in most doctor and nurse cultures. Providers are taught to fix. Yet, we’ve found, that without first understanding the patients’ goals and then uncovering the obstacles that stand in the way of their goals, our sickest patients don’t feel compelled to change.

How does it work? Instead of telling patients to change, we guide them to express their own commitment out loud, which has been shown to improve patients’ ability to actually make a change.

‘Fishing with My Grandson’

When I asked one of my patients with a chronic breathing disorder about his goal, he replied, “I’d like to be able to fish with my grandson.” Later, at his appointment and others, I asked questions about what might be getting in the way of his goal. “I can’t breathe outside” or “I can’t leave the house without my breathing device.” We discussed the obstacles and set forth reasonable small goals to progress him forward. Each time he achieved a goal, he was motivated to set another.

My patient was aware of his barriers. With motivational interviewing, he became empowered to learn how to overcome them.

Numbers Reflect Success

A successful population health program is an investment in time and money, but the effort pays off. As last year showed, Austin Regional Clinic’s success has the numbers to back it up:

  • More than $3 million in 2018 shared savings, bringing the total to almost $25 million in the past eight years
  • An 80% screening rate for depression and fall risk, up from 38% just two years previous
  • 12% of diabetic patients moved to “good controlled” from “poor controlled”
  • 73% of our Medicare population is up to date on their colorectal screenings, up from 65% a few years before

Every year we set new population health goals, raising the bar just a bit. Admittedly, improving population health is a marathon, and we are only in the first leg of the race. Enhanced predictive analysis using artificial intelligence and machine learning will guide us to the patients for whom we can make the greatest impact on their health.

Our philosophy concerning our patients is unwavering — to not just consider each patient’s illness, but to see the person. To understand their values, their lives, and their support. To listen and to empower.

The most accurate predictive analysis cannot compel a patient to change — a patient’s will does that … and the dream to fish with a grandson.

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Winonah Hoffman, BSN, RN

Winonah Hoffman, BSN, RN, is the director of clinical transformation for Population Health and Clinical Quality at Austin Regional Clinic.

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