Identifying priority populations is critical for setting health equity goals, but pinpointing individuals is the key to improving health outcomes.
Addressing health equity begins with evaluating data to identify disparities in specific outcomes and distinguishing the populations experiencing them. This evaluation then informs your health equity goals and planning.
But if you stop at just identifying disparities and priority populations, the resource-limited nature of interventions may prevent you from closing the gap Conducting interventions on entire populations is logistically and financially infeasible. Successfully advancing health equity hinges on your ability to pinpoint the specific individuals within your priority populations at the highest risk for adverse outcomes.
To identify high-priority individuals for targeted interventions, you will need the ability to discern their unique clinical and social circumstances and understand how each of these factors contributes to overall risk for specific, undesirable outcomes.
Precise and actionable individual-level risk stratification is key to addressing health disparities with targeted intervention programs. The more accurately you are able to pinpoint impactable, high-risk individuals, the more effectively you will be able to advance health equity.
With today’s artificial intelligence (AI) tools, you can pinpoint high-priority individuals with the utmost accuracy based on their specific, impactable risk factors—going beyond simple stratification by race and ethnicity.
These tools can analyze all clinical and claims data available to you to build predictive analytics specific to your populations, outcomes of interest, and goals. To maximize the actionability of predictions, some tools may also be able to incorporate the individual social needs assessments you will be collecting as required by the ACO REACH program, as well as public data on social determinants of health (SDoH).
Prioritizing at the population level helps you set appropriate health equity goals. To achieve these goals, you’ll need tools that enable you to pinpoint high-priority individuals and run targeted interventions that more effectively improve outcomes, reduce costs, and eliminate disparities.
