Population Health

Improving the health of an entire population requires a shift in thinking and looking at the delivery of care beyond the four walls of a clinic or hospital. Compass aligns payers and providers for value-based purchasing, equips providers and healthcare systems for service delivery transformation and engages community organizations to sustain healthy behaviors.

Integrated Delivery Network Development

Integrated delivery networks (IDN) are comprised of physicians working with hospitals to form a healthcare ecosystem. IDNs build on successes leveraging community resources and meaningful strategic partnerships to improve access, quality of care and cost-savings. The goal is value-based integrated care through strategic partnerships, coordinated care processes, collection of data and electronic systems to track services and provide a comprehensive view of consumer health. Compass works to advance IDNs.  

Compass dedicates leadership, program directors, physicians, nurses and data analysts with the necessary expertise in healthcare, education, information technology and quality improvement to make this happen.

How Compass Can Help
Evaluate and assess organizations and populations to determine baseline and foundational capabilities Facilitate community involvement in the Accountable Communities of Health Model Provide education, training and virtual communication sessions Align resources and tools for fiscal and program management	Convene organizations to examine and determine health transformation direction Support cross-sector electronic referral systems to connect healthcare providers with community organizations and social service agencies Utilize data for rapid cycle improvement

Addressing Social Determinants of Health

Social determinants of health (SDOH) have a significant impact on health outcomes. Evidence indicates that 80 percent of health outcomes are attributed to factors outside healthcare walls. SDOH implications are compounded for high-need, high-cost populations that need preventive health services and coordinated care to improve health, lifestyle and minimize personal costs. 

Compass has a dedicated, diverse team working together to address SDOH factors and barriers limiting positive health outcomes.

How Compass Can Help
Facilitate statewide SDOH resource campaigns Encourage hospitals to utilize community-based social needs solutions Baseline environmental scan assessing existing community social services capacity and accessible public directory of social services Provide evidence-based SDOH education and training	Partner with organizations that have key investment in SDOH solutions Initiate community-based population health strategies with health systems to include integrated social support systems

Human-Centered Care Design

At the center of healthcare transformation is the patient. As healthcare continues to shift from volume to value, the way care is delivered is changing. Human-centered design is an approach to interactive systems development that aims to make systems usable and useful by focusing on the users, their needs and requirements. Human-centered design enhances effectiveness and efficiency, improves human well-being, user satisfaction and sustainability.

Compass employs a diverse team of expertise to support human-centered approaches at all levels. The Compass team engages directly with personnel from direct care to the C-suite and beyond to design and foster organizational cultures of person-centered safety and engagement.

How Compass Can Help
Promote person-centered care design into the application of all clinical and community-based interventions Utilize assessment tools to measure patient activation and facilitate targeted personalized interventions to enable positive behaviors and buy-in Align strategies and best practices for inclusive, intentional interactions and care experiences throughout systems of care Assist providers, administrators and systems apply human-centered design approaches in root cause analysis, strategic planning and performance improvement strategies, including experience/journey mapping and overlay Implement meaningful approaches to patient engagement and activation shown to improve outcomes, satisfaction and joy in practice	Use the full spectrum of person and family engagement strategies to bring patients, caregivers and consumers on board as equal players in care Develop and implement protocols and procedures that establish person-centered design and engagement as the standard operating practice  Provide technical assistance and training on human-centered care design approaches, methods and strategies from initiation to systematic application Align person-centered engagement and design principles with patient safety and value-based care goals including quality and outcomes

Community Coalition Development

The health and well-being of populations are dependent on many factors, one being a strong community coalition. Community coalitions built on diverse, collaborative partnerships with a shared vision positively impact the populations they support.

Compass is equipped to support your efforts in healthcare transformation and community coalition development. Compass' experienced leaders focus support work around community integration, SDOH and human-centered design while using research and analytics to ensure alignment between clinical and community efforts.

How Compass Can Help
Promote a culture of transparency to allow continuous improvements and outcome effectiveness in community coalition work to accelerate necessary change Work collaboratively with clinical and community organizations to encourage joint development and implementation of community health needs assessments to achieve targeted health outcomes Support person and family engagement statewide strategies through awareness and education to enhance participation Lead professional development opportunities at the local and state level	Increase efficiency and effectiveness of collaborative efforts empowering meaningful patient-centered change Examine critical community partnerships and opportunities for alignment at national, state, and local levels to maximize impact and sustainability Expand provider engagement for community-level integration Measure, analyze and report outcomes for clinical-community effectiveness and cost efficiency

Population-Based Community-Applied Interventions

Integrated clinical and community efforts maximize outcomes and the impact on communities on a large scale. Combined community initiatives and population health strategies effectively promote engagement and increase access to care. Evaluating the uniqueness of each community while incorporating assets and challenges can help determine a roadmap for success in population-based community-applied interventions.

Compass has a proven track record of improving outcomes to support community population health needs. Compass leadership, program directors, support staff and data analytics team have extensive experience in both clinical quality improvement and public health application.

How Compass Can Help
Incorporate continuous quality improvements into optimized referral systems for integration of community and clinical care Utilize relevant data to guide necessary improvements and transformation Perform cost of care analysis to ensure quality care can be achieved at a lower cost Tailored technical assistance, on-site and virtual consultation, and professional development opportunities Adapt with economic variabilities and address SDOH needs to align communities to better serve their populations	Convene key leaders from providers, payers, government and community organizations to advance sustainable healthcare tools and resource sharing Align population-based community-applied interventions within the Accountable Communities of Health model and guide data-driven strategies to successful implementation Create innovative solutions to support trending healthcare transformation efforts   Oversee implementation and execution of select statewide strategies to advance population health efforts