How local government can use proactive health monitoring and outreach to improve community health outcomes

For many years prior to the COVID-19 pandemic, health care stakeholders have championed improving health outcomes through a population health management (PHM) approach that includes targeted interventions to high-risk individuals. The pandemic brought health awareness to the forefront with community leaders regularly addressing the impact COVID-19 has had on their local communities. This has presented mayors and other city leaders the opportunity to not only discuss COVID-19 cases, testing and vaccination information, but to address underly health issues and chronic illness. The pandemic has opened the door for real community health leadership.

When it came to community health, my time as mayor of Rockford, Ill., taught me the difference between actionable data that drives engagement and improves results versus interesting data that provides high level insights but has practical limitations.

The Affordable Care Act of 2010 (ACA) requires tax-exempt hospitals to create a community health needs assessment every three years. Many communities (including my own) were already doing some type of community health survey like this prior to the requirements of the ACA through local agencies such as United Way or other local health organizations and partnerships.

Unfortunately, these reports by themselves do not create actionable data. While our work helped us identify and examine trends, we were limited in our ability to turn that high level population health data into effective clinical interventions. These reports, while insightful, also seemed at times to reinforce pre-existing narratives about our community more than drive improvement.

Mayors across the country have access to localized and actionable health data. They simply need to look at their 911 call center. Every community has members of the public who become “frequent fliers” for police, fire and EMS. These are citizens with chronic health issues that often use the 911 system to access care.

A breakthrough emerged in my community when we started to integrate the understandings that came from our high level Community Needs Assessment with personal information about our citizens that came from our frontline outreach workers and our 911 call center. We also created governance processes that pulled together multiple providers to coordinate efforts and address a broad spectrum of needs including health, housing and social services.

With this approach, our Fire/EMS service became licensed in 2015 to provide Mobile Integrated Health. For the first time, instead of simply transporting a citizen in need to a hospital emergency room, we could identify, engage and care for our high-risk community members at their homes prior to the 911 call, all while maintaining patient confidentiality. The results of the approach have been impressive so far with significantly reduced hospital admissions and costs for enrolled community members.

We extended the same personalized population health approach to our public employees. As a self-insured large employer, we saw firsthand the impact in continuously escalating health care costs and poor health outcomes for our people. We recognized that the traditional fee-for-service approach of providing care to our employees tended to de-emphasize lower cost prevention and intervention and focus on higher-cost disease management and treatment. Beyond the direct costs, poor health also led to higher numbers of workplace injuries, disability claims and risk to members of our community.

In order to intervene early, consistently and effectively, we moved away from the traditional fee-for-service model. We hired a national worksite health care company on a fixed-fee basis that worked exclusively with employers providing primary/preventive care. They also guaranteed results based on the health care triple aim—lower costs, improved health outcomes and high patient satisfaction. We worked to identify employees with chronic health conditions and provided high-quality primary care and health coaching to keep them engaged in their own care. After six years working under that model, the city has seen more than $23 million in savings from its prior health spending trend.

Every community with a 911 call center is continuously receiving data on the most at-risk members of its community. Moreover, every community has the ability to leverage its own health care spend for its employees to drive change in health care delivery. Communities that can work effectively in partnership with insurance companies, hospital systems and other medical providers can proactively intervene to address chronic health conditions, mental health and substance abuse problems—for both citizens and employees. By using data to identify at-risk individuals and intervening early, local governments are experiencing better outcomes for constituents and lower costs for taxpayers.

Larry Morrissey is the former mayor of Rockford, Ill., and current vice president of government affairs for Marathon Health. This article is the first in a three-part series that will exam three major factors affecting local governments’ ability to tackle health care challenges and save money on their health care spend and the implications it has for their constituents and employees. In his next article, Larry will explore expanded and enhanced access to health care.