Population health management needs to be responsive to patient needs and has to be efficient in order to save costs and improve outcomes. In 2013, Earnest Carter, MD deputy health officer at Maryland’s Prince George’s County Health Department had the vision to involve local stakeholders to work on social issues that influence an individual’s ability to live a healthy life. He then received a funding to improve population health in the community.

In 2016, Prince George’s partnered with HealthEC, which is a value-based care technology and services vendor to maximize local care coordination efforts. This focus came with the understanding that patient care data integration is the edifice of building an infrastructure to support healthcare analytics.

HealthEC helped and collaborated in many ways towards this endeavor. Its social determinants of health and disease-based assessment tools were responsible for identifying the roadblocks and expedite the access to the resource. Infact, the local community contributed too by addressing the holistic care needs of the residents across many diseases and social issues.

Prince George’s County Health Department has worked along with communities with the purpose of creating programs that promote healthier options like exercise programs, support groups and more.

The results were impressive; Prince George’s work to reduce the number of hospital readmissions has saved one hospital more than $1 million as recorded by the health department.

HealthEC worked along with local HIE, the Prince George’s County Public Health Information Network, with the aim to provide instant access and distribution of patient information, to share among authorized providers involved in patient care. This includes primary care specialists and hospitals.