Know Thy Patient

Traditional disease-based clinical programs have been effective in managing and treating specific medical conditions, but often fail to effectively address the complex needs of patients, particularly with respect to barriers to healthcare access (e.g., social vulnerabilities, transportation barriers, lack of insurance coverage). In close collaboration with Parkland, PCCI developed a novel, advanced analytics process called Know Thy Patient (KTP) to group patients other than by their primary disease or diagnoses (e.g., diabetes, hypertension).

By integrating and analyzing metrics associated with barriers to health care access — social vulnerabilities, transportation barriers, lack of insurance coverage — into the clinical context, health strategies adopting these cohort-similarity approaches can more readily incorporate a wider variety of patient centered, whole-person approaches to care, such as integrated practice units, targeted digital programs, virtual and in-person support groups, and focused outreach and communication.