In the world of population health and wellness, engagement happens when an individual is an active participant in improving or maintaining their health. It often requires more than office visit notes for a patient to let go of unhealthy habits, and it takes more than a water cooler conversation for wellness to occupy the minds of employees. In 2013, Health Affairs published an excellent article that defined engagement as “active partnership.” A literature review funded by the Agency for Healthcare Research and Quality (AHRQ) concurs. Researchers concluded, “Patient engagement can be defined as the desire and capability to actively choose to participate in care in a way uniquely appropriate to the individual, in cooperation with a healthcare provider or institution, for the purposes of maximizing outcomes or experiences of care.”
Optimal health occurs when individuals, families, friends, health professionals, and communities work together to achieve a common goal, and personalization is essential. Population health and wellness professionals must consider an “individual’s knowledge, skill, and confidence for managing his/her own health and health care,” according to Health Affairs. They must also be aware of and accommodate the individual’s willingness to make needed changes.
It makes sense that individuals who participate in healthy behaviors experience improved health, and research has confirmed this. Active involvement is key to improved health, as individuals who are engaged in caring for their health have healthier habits, adhere to treatment plans, use emergency services less often, and have a higher quality of life. One survey found that employees who are engaged in their workforce wellness programs are more likely to have healthy behaviors, be loyal to their jobs, and be motivated and productive at work. Patients who actively participate in their health, including decision-making, also have better outcomes and lower costs.
Population health managers spend a lot of time thinking up ways to entice individuals to become active participants in healthy behaviors—and with good reason. Only one-third of patients are highly engaged in their health, according to a New England Journal of Medicine Catalyst Insights survey on patient engagement. However, according to a Health Affairs Health Policy Brief, “People actively involved in their health and health care tend to have better outcomes—and, some evidence suggests, lower costs.” Engagement may involve “both process and behavior” and be influenced by:
Population health and wellness professionals now walk the tightrope between knowing too much and too little. Genomics and precision medicine can help predict disease and an individual’s response to interventions and treatment. Consumer data and data from wearables such as fitness trackers can reveal much about an individual’s preferences, habits, and motivations. Increasingly, individuals are willing to share type of data with their healthcare teams.
However, the healthcare sector is under persistent cyberattack. More than 11 million individuals were affected by healthcare breaches in 2018. Healthcare security lags behind all other sectors, according to the tenth annual Online Trust Audit & Honor Roll. A population health team must include cybersecurity and privacy specialists, such as a dedicated security officer and privacy officer, that ensure all processes, policies, and procedures are in place—and followed. Verification by an independent accrediting board is also advisable. This will ensure populations that their data are kept confidential.
Health and wellness professionals use big data and AI to stratify populations. Useful data include self-reported data gathered from a health risk assessment (HRA) or doctor’s office visit, neighborhood statistics, and consumer details. Information such as where a person lives (their ZIP code) and where they go to church wields more sway in a person’s health than genetics. As former Surgeon General Regina Benjamin observed, health “occurs where we live, where we work, where we play, and where we pray.” A recent study found that care coordination and community outreach interventions could reduce health costs and improve health outcomes.
Successful population health management relies on an engaged population—one in which individuals are active participants in both decision-making and follow-through in behaviors that will improve their health and wellness. This differs from compliance, where an individual simply follows orders. Engaged individuals seek out the best approach for their optimal health. This is similar to a precision medicine model in which patients are partners in their care.
The Centers for Medicare & Medicaid Services patients first initiative aims to empower patients to be active participants in their health and wellbeing. Our guide outlines four ways to achieve patients first, value-based care.
Population health and wellness professionals increase engagement when they consider interventions that address all dimensions of behavior change. One of the first steps is using data to discover what needs to be changed. There are many data points to review, including claims data, consumer data, and self-reported data from Health Risk Assessments. The next step is determining whether an individual is ready to change. James Prochaska and Carlo Di Clemente developed the transtheoretical model, also called Stages of Change, to assess a person’s change readiness. Behavior change messaging depends on what stage an individual is in.
What does it take for individuals to be proactive about their health? For some, all it takes to engage in wellness is to be made aware of their health risks and learn what they can do to prevent long-term health problems or improve current conditions. But for many more, simply providing information isn’t enough to elicit behavior changes. Why don’t they engage? The primary reason cited by people who do not participate in health and wellness programs is that the offered interventions are not personally relevant to them (37%). Population health and wellness professionals must use the data available to them to personalize not just the interventions but also the messaging and methods.
Health and wellness professionals can learn from the consumer model for engagement. C2B Solutions specializes in consumer segmentation models and consumer motivators and behaviors. As C2B Solutions CMO Brent Walker observed, “Knowing your customer/consumers is only one part of engagement. Engaging a consumer in a way that inspires action also involves knowing the form of communication your customer is receptive to, as well as the actual timing of the communication. These factors play into message receptivity.” Analyzing consumer data and self-reported data gathered via an HRA is useful for identifying habits and conditions that require intervention. Behavioral and psychographic segmentation helps determine the timing and approach that will increase an individual’s receptivity. Consumer data and self-reported data gleaned via an HRA can provide a good look at an individual’s behaviors and motivators.
As Welltok CEO Jeff Margolis observed, “There is strong agreement among healthcare experts that medical care and genetics drive only about one-third of health status.” What else is there? Population health and wellness professionals can learn a lot by examining consumer data. By “amalgamating consumer data, which is a much stronger predictor of how a person will or won’t interact with available health resources, with medical and claims data,” population health managers can tailor the behavior change approach to each individual, says Margolis.
Consumer data can help identify who is most likely to engage via text or phone call, who can be incentivized with rewards, and which individuals will have difficulty forming new habits. For example, a direction-taker simply needs to be told what to do. Other individuals need to know their options, with all the possible ramifications and outcomes. Still others need instant gratification. Machine algorithms that analyze consumer data, self-reported data from a health appraisal, claims data, socio-demographics, and medical data can even allow population health managers to pinpoint the kinds of messaging that will achieve engagement and desired outcomes.
There are hundreds of publicly available consumer datasets, and companies like Welltok have developed proprietary machine learning algorithms that have identified at least 800 variables that are indicators of consumer behavior. “Every 10 seconds, our machine-learning model generates a new set of predictive data insights,” notes Margolis.
Optimal health requires “wholeness,” not just physical health. The Substance Abuse and Mental Health Services Administration (SAMHSA) identifies eight dimensions of wellness that must be fulfilled for wellbeing.
A holistic approach to health can improve wellness engagement. The dimensions of health are interconnected, so improving one of them will positively impact the others. Population health and wellness professionals who take a holistic approach will work on improving weaker dimensions, knowing the other dimensions will also benefit. For example, an individual in psychological distress might want to focus on coping. However, by examining all the dimensions of wellness, a population health manager might notice that the individual sleeps poorly and is inactive. The motivation to feel less stressed would increase the individual’s willingness to take a few 10-minute walks each day and include deep breathing exercises as part of a bedtime routine.
The concept of health as complete wellbeing has been around in the Western world since at least 1946, when the World Health Organization defined health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity” in its constitution. WHO declared wellbeing to be “one of the fundamental rights” of individuals, and its definition of wellness is similar: “the optimal health of individuals and groups,” including physical, mental, social, spiritual, and economic aspects.
Health behavior researcher Victor Strecher, PhD, wondered about the root causes of behaviors that lead to chronic diseases, suicide, and addiction. He discovered that the triggers were “loss of wellbeing, loneliness, isolation, alienation, and anomie.” Anomie is instability brought on by the loss or breakdown of purpose, standards, or values.
Strecher’s current research is focused on whether sleep, presence (i.e., mindfulness), activity, creativity, and eating positively influence purpose, energy, and willpower. He believes the antidote for disease is “a strong self-transcending purpose” and considers the act of helping people discover their purpose to be “precision wellbeing.”
Health professionals assign risk scores and stratify populations based on data from claims, chart notes, self-reported information on health habits and psychological state, and social determinants. Today’s Internet of Things makes it easier than ever to combine large datasets to predict needs and outcomes. Analyzing clinical and non-clinical metrics helps population health and wellness professionals predict the risk of future disease, assess complications, and design treatments to intervene upstream of costly problems and improve outcomes. Data to consider include exercise, psychological state, medications, access to care, health literacy, weight, age, personal health history, social support, hospitalizations, smoking status, income, biometrics, and geographic location.
Why don’t people participate in wellness programs? One in five people say they didn’t know about them, according to a Welltok survey. However, this isn’t because population health and wellness managers aren’t communicating. It’s just that the information wasn’t recognized, understood, or received. Personalized messaging—delivered in a format that is best received by an individual—may be key to improving engagement. The National Institutes of Health Pink Book outlines communication best practices, such as targeted messaging based on motivators, lifestyle factors, social media use, or technological expertise. Becker’s Hospital Review outlined six approaches that encourage active participation that align with government advice:
Up to 90 percent of an individual’s health is influenced by social determinants of health (SDoH). An effective engagement strategy requires working with social services, community organizations, churches, and government agencies to address SDoH factors that negatively impact health. Some questions to ask when considering SDoH barriers include:
Employee wellness professionals must consider SDoH in their workforce. The fact is, financial stress, exposure to violence, inaccessibility to healthy foods, and transportation issues negatively impact an employee’s health—and, likely, a company’s bottom line. Employers can address SDoH issues when they:
By addressing SDoH upstream of disease onset, population health and wellness professionals can help remove engagement roadblocks and improve health outcomes.
Population health and wellness professionals can boost engagement by connecting with people as individuals, not just with the collective community. One way to do this is to involve individuals in their personal care plans by listening to their concerns, values, and goals. When Eric Dishman met with his cancer physician, he forced the doctor to write: “Patient goal: low doses of drugs over longer periods of time, side effects friendly to skiing.” Today, Dishman advocates a personalized, care-anywhere approach to medicine and is the director of the All of Us Research Program. Advances in technology can build predictive models that allow for targeted approaches in care and help pinpoint engagement strategies. However, population health and wellness professionals can’t know what inspires an individual to take an active role in their care unless an individual tells them. Shared decision-making engages individuals in their care from beginning to end.
Wellsource analyzed health risk assessment data from more than 24,000 individuals covered by Medicaid to see the influence common social determinants of health measurements might have on overall population health.
People who embody health and wellness can inspire others to actively participate in healthy lifestyle behaviors. Celebrities who are willing to tell their stories and share their journeys can give others hope and empower them to take an active role in their own health. Think: Lady Gaga (chronic pain), Magic Johnson (HIV), or Gwyneth Paltrow (postpartum depression). But population health and wellness professionals don’t need to stress if they don’t have celebrity connections; local heroes can be even more influential. Leaders and peers who model engagement might be old or young, activists or introverts, white or blue collar, but they all have a voice—and a significant influence—that will inspire populations to engage.
Healthcare professionals have turned to technology such as wearables, telehealth, texts, and messaging to improve patient engagement, but the technology with the most engagement potential is shared medical records. This type of interoperability (electronic health records that are shareable not just throughout a healthcare system or across all of healthcare but also with the individual) makes it easier for people to interact with their medical records and with care providers. Patient portals, online HRAs, and digital interventions are good first steps. Applications that are fully integrated with social media, shared notes, and wearables can help individuals engage with their health.
Research by the RAND corporation found that incentives increase participation by about 20 percent. The majority of workforce participants will engage if offered the right incentive—especially millennials (98%)—but a significant portion of older individuals also said they could be motivated by incentives. Common incentives include discounts on insurance premiums, cash rewards, gym memberships, and prize drawings; larger incentives increased participation by just a few percentage points. The bigger factor in participation, according to a Harvard Business Review survey, is effective communication. The majority (69%) of nonparticipants who indicated they were willing to be actively engaged in a wellness program said they didn’t participate because they didn’t know about it.
Many individuals lack the skills needed to understand prescription instructions, follow lifestyle medicine recommendations, interpret test results, and understand health risks; some are technologically challenged. Reduced health literacy increases the risk of unhealthy habits, poor health, hospitalizations, and early death. The responsibility of clear communication rests on population health and wellness professionals. The Health Literate Care Model recommends that health professionals respectfully approach all individuals “as if they are at risk of not understanding health information.” Because Medicare populations are at an increased risk for literacy complications, the Gerontological Society of America offers 29 tips for effective communication with older patients.
The AHRQ describes some ways religion, culture, beliefs, and ethnic customs influence an individual’s values, lifestyle choices, interactions with healthcare providers, and engagement in interventions. Here are some examples:
It is essential for population health and wellness professionals to be aware of and affirm cultural differences. They must also respectfully ask each patient about their beliefs and customs, as they may not adhere to traditional cultural norms.
Everyone has a right to be healthier, but do they have access and opportunity to be the healthiest they can be? That is the concern of health equity. As the Robert Wood Johnson Foundation (RWJF) defines it, “Health equity means that everyone has a fair and just opportunity to be healthier. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” Population health and wellness efforts must identify health disparities and create strategies to reduce them. This requires collaboration with individuals, agencies, organizations, and systems to remove barriers to optimal health, including socioeconomic determinants, racism, and culture.
Strecher’s current research is focused on whether sleep, presence (i.e., mindfulness), activity, creativity, and eating positively influence purpose, energy, and willpower. He believes the antidote for disease is “a strong self-transcending purpose” and considers the act of helping people discover their purpose to be “precision wellbeing.”
It is essential that individuals feel secure, valued, and accepted, particularly when considering issues of addiction, stress eating, excessive alcohol use, and psychological distress. When individuals feel their answers to HRA questions about mental health will be kept confidential, for example, they are more likely to be honest. A culture that removes the stigma of mental health issues or obesity goes a long way in helping people engage in interventions. Plus, there’s a bonus for corporations, which benefit in terms of productivity, teamwork, loyalty, and innovation. Conversely, a culture of blame and shame “robs organizations of important moments for innovation, improvement, experimentation and collective learning” and can result in unsafe physical environments. Population health and wellness professionals can promote psychological safety by:
Support from the company CEO and managers is imperative for achieving employee wellness engagement. Unless C-suite executives are personally passionate about wellness—and even then—a wellness program that does not have business sense will not have a long lifespan. Employee wellness managers must work with management to discuss the benefits and costs of the wellness program. They must also insist that executives model healthy lifestyle behaviors. Their buy-in shows employees that the company has made wellness a priority. Top-down modeling of health habits is one of the six best practices of award-winning workplace wellness.
According to Chris McReynolds, CEO of Wellsource, creating a culture of wellness has to start with the C-suite.
The delivery methods for communication and interventions will depend on the population. Nine in ten millennials (born 1981–1996) own a smartphone, but a Pew Research Center survey found that tech use declines with age, particularly for those aged 75 and older; four in ten seniors now own smartphones. Many seniors need help with electronic devices, as only 26 percent say they are confident in their ability to find information online. Some seniors, particularly those with higher education and incomes, are more comfortable with digital technology. But even then, declining motor skills and failing eyesight can hamper their technological prowess. Analyzing information from electronic health records, consumer data, ZIP codes, and health habits gleaned from an HRA can determine whether texts, mail, email, automated phone messages, live telephone calls, apps, video calls, or in-person coaching are the best ways to engage an individual in their health.
Sometimes individuals want to make behavioral changes that will improve their health and wellbeing but cannot implement these changes for various reasons. It may be fear of failure that holds them back. For example, an individual might feel it is impossible to lose weight. Perhaps they are ready to improve their nutrition habits but don’t know how to cook or what to eat. Or maybe they need help creating and living within a budget. These roadblocks can be resolved with counseling and education in a group setting or one-to-one. Do they forget to drink water, take prescriptions, or go for a short walk? Short texts, emails, or calls can be a welcome reminder.
A culture of wellness is crucial to employee engagement. Research shows that a comprehensive wellness program also increases participation. Beyond that, population health and wellness professionals should ask employers to identify influencers among the workforce and enlist them as wellness champions. Many employees will be motivated by C-suite executives and managers who model healthy behaviors. Another strategy is to use HRA data to determine where a majority of employees are ready to make a change and design an intervention around this information.
Data analysis is the most important step in engaging Medicaid populations. Population health and wellness professionals must identify roadblocks to wellness before they can promote healthy behaviors such as well-checks and healthy nutrition. SDoH such as finances, safety, and transportation must be addressed before Medicaid members can engage in healthy behaviors.
As a group, seniors account for a third (36%) of healthcare expenses in the United States. A systematic review of 23 studies on engaging seniors in research suggests approaches that can help Medicare members be active participants in their own health and wellness:
Another study concluded that obtaining meaningful engagement in decision-making requires identifying barriers such as language, literacy, feeling alone or abandoned, cognitive issues, emotional or physical frailty, and time constraints. While many seniors don’t have smartphones, 67 percent of people aged 66–74 use the internet. About four in ten seniors aged 75 and older use the internet, with more than 80 percent using email. Many seniors are willing to engage in digital technology, but they do need to be patiently taught. A recent Accenture survey found that seniors are interested in using technology for self-care, health-monitoring wearables, consulting online communities for peer reactions to care plans and interventions, accessing and managing health records, and navigating their care. Another survey, conducted by Alignment Healthcare and research firm Toluna, found that seniors are interested in technology that allows them to talk to a doctor or case worker on a tablet, manage chronic conditions so they can remain independent, and receive clear direction on how to manage a health problem and improve their health. It seems three keys to Medicare engagement are communication, respect, and education on the use of technology to manage chronic diseases and improve health outcomes.
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