Population health done three ways

Healthcare leaders explain the technology, process and grit needed to improve patient care
By Karen Handmaker
02:56 PM
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The rise of population health management in recent years has been one of the most significant strategic shifts in the healthcare industry. It not only brings its own benefits to patients and providers; it is also an enabler of other changes – not the least of which is the transition from fee-for-service to value-based billing.

The most important change that has resulted from PHM is the emphasis on proactively keeping patients healthy – or healthier – rather than simply being reactive (i.e., treating the sick). This approach applies not just to the patients providers regularly see, but to everyone on their patient panels. As accountable care organizations, bundled payments, shared risk and other payment innovations continue to expand in popularity, PHM becomes as important to the financial health of healthcare organizations as it is to the physical health of their patients.

Yet while many healthcare organizations see the benefits of PHM in the abstract, they may struggle to visualize how it can be applied to their specific circumstances. Some may feel their patient population is too small to justify the investment in technology and people PHM requires. Others may question whether PHM will scale sufficiently to encompass their entire patient population.

Becoming a must-have

Population health management continues to gain momentum as a strategy for improving care quality and outcomes while preparing healthcare organizations for the transition to value-based care. But there are still concerns regarding how well it can scale to fit the needs of the many types and sizes of providers in the U.S.

The three examples included here demonstrate that with visionary leadership, a commitment at all levels to driving clinical and financial improvement and the right technology platform, PHM has the ability to help nearly any organization manage its patient population more effectively. Their stories also deliver concrete evidence that placing a priority on managing populations can reduce the costly and debilitating effects of chronic conditions while promoting overall wellness within the community. Clearly, PHM is becoming a must-have for organizations that want to thrive in the brave new world of healthcare.

How one large organization is taking on the pop health challenge, next page.

The large: Orlando Health

By Tawnya Adkisson, director of care coordination

Based in Orlando, Fla., Orlando Health is one of the state's most comprehensive private, not-for-profit healthcare networks. Its 1,780-bed family of eight hospitals serves nearly 2 million Central Florida residents and roughly 4,500 international visitors annually.

The health system has been an enthusiastic supporter of the ACO model, participating in the Medicare Shared Savings Plan and Cigna's ACO program since 2013, joining Florida Blue's program in 2014 and AvMed's in 2015.

It was concern for the community as a whole that first led Orlando Health to PHM. Moving from a reactive mode to proactively encouraging patients to seek recommended care and close care gaps on the scale required, however, would not be easy since data about Orlando Health patients is held in several disparate electronic health record systems that are not compatible.

The health system needed a way to obtain a complete view of the patient. While the claims system could provide that view, the data might be six months old. And even if it could achieve a comprehensive view, the resources required to scan through millions of records manually to narrow the list to the most at-risk patients, identify care gaps, engage with them to set up appointments for the appropriate care and evaluate the program's performance were well beyond Orlando Health's budget.

To solve these issues, Orlando Health created a clinically integrated network by implementing a comprehensive PHM technology that could act as a pseudo-health information exchange. The technology already had the ability to interface with and accept data from the multiple EHRs and practice management systems used by the health system's 500 employed and nearly 3,000 affiliated physicians. This allowed the PHM technology to become the single reference source for patient data across all providers.

With that capability in place, the next step was to build patient registries for patients who met certain criteria, such as having one or more chronic conditions or those who fit the recommended parameters for preventive screenings such as mammograms or colorectal exams. Orlando Health then used the PHM platform to automatically contact targeted patients via phone, email and text. Messages were sent informing patients of care gaps and recommending they contact their primary care physician to schedule an appointment. As scheduled appointments approached, the PHM platform sent automated reminders.

In all, Orlando Health was able to identify a list of nearly 300,000 patients with some form of care gap, whether it was around a chronic condition such as diabetes or chronic obstructive pulmonary disease, or being overdue for preventive care that could help them avoid a costly emergency department visit or hospital stay later. After one year (April 2014 – March 2015), it was clear that the PHM program was working.

Results included:

  • 7 percent increase in diabetic patients who had current HbA1c tests
  • 10 percent increase in preventive mammograms
  • 9 percent increase in preventive colonoscopies
  • 15 percent increase in falls-risk screenings
  • 10 percent increase in patients who were screened for depression and had a plan of care developed to address it
  • 22 percent overall increase in the number of patients who took action to close a care gap after receiving an automated communication

The PHM effort paid off financially as well. Orlando Health was able to generate a combined $6.6 million in shared savings from its ACO contracts with MSSP and Cigna in 2013. The PHM platform was also instrumental in helping all but two of its PCPs meet Level 3 criteria as Patient-Centered Medical Homes by Q1 2015. As local PCPs learn about the PHM platform's ability to impact patient health and aggregate EHR data across platforms, more are requesting to become affiliated with the health system. These early successes continue to compound today.

How mid-size organizations apply population health initiatives: Next page

The mid-size: Northeast Georgia Diagnostic Clinic

By Marlene McIntyre, director of quality, risk & population health

Northeast Georgia Diagnostic Clinic, NGDC, is a provider of medical care and treatment in the Northeast Georgia area.

Since its humble beginning in 1953, the privately owned physician practice has grown into a multi-specialty practice of 36 physicians and 11 mid-level providers across seven specialties.

In addition to the primary location in Gainesville, Ga., which includes full-service radiology, lab, pharmacy, diabetes education, nutrition and physical therapy services, the practice also has additional offices in Braselton and Athens, Ga. One of NGDC's greatest advantages is the ability to offer a broad range of services under one roof – from primary care, to specialists and supportive therapy services.

NGDC's patient population is somewhat unusual in that it is roughly 60 percent Medicare fee-for-service, with the remaining patients being largely commercially insured. The practice is a National Committee for Quality Assurance-recognized Level 3 patient-centered medical home and has a robust care management program, which places a significant focus on managing care transitions post-hospitalization, chronic disease management, and the management of high-risk patients through shared savings programs and a community clinical integrated network.

It is critical for NGDC to be able to gather and review data from multiple venues on the healthcare continuum, and combine that data with its own health information management system, HIM,  in a timely fashion to gain a 360-degree view of patients' needs, identify care gaps and generally help them better self-manage their care.

With more than 50,000 patients in its population, NGDC care providers realized attempting to manage the needs of those patients manually would quickly overwhelm the practice's limited resources. Instead, the organization opted to implement a PHM platform that would help it build patient registries based on chronic conditions, identify care gaps, perform outreach, remind patients of their pending appointments, and otherwise assist in supporting quality and performance-improvement programs. The platform is also enabling technology for the HIM, bridging the gap between multiple patient systems to provide a single source of information about the care NGDC patients have received.

The practice's care management and PHM programs support three primary initiatives:

  • The care management program helps ensure patients who are transitioning back home following ED visits or admissions to the hospital receive the follow-up care they need at NGDC. The platform automatically reviews data from the hospital systems to identify needs such as scheduling follow-up visits, performing post-discharge medication reconciliations and ensuring that complications and concerns are addressed quickly, before they lead to readmissions.
  • Participation in the Centers for Medicare & Medicaid Services' chronic care management program, which is designed to help patients with two or more chronic conditions that put them at greater risk for complication or decline. The organization uses the PHM platform to risk-stratify patients, manage care coordinator workflow, and identify patients that are due for follow-up communication. The system also provides a comprehensive look at each patient including chronic condition needs, preventive care needs, care gaps and opportunities, medications, and appointments.  The PHM platform also provides the care coordination team with a quick and easy route to a full view of the patient, which they otherwise would have to gather from visiting numerous screens in two different systems. While the program pays $40.59 per patient per month for care coordination, it also benefits the group's overall population health program and allows it to engage with patients earlier and more frequently, tackling those patients that are often "below the waterline," before they become high-risk.  Without the automation and efficiency gained from the PHM platform, it would be impossible for the organization to manage the hundreds of patients it has enrolled. 
  • The third is a standard care coordination category for patients in need who don't meet the criteria. This category includes high-risk and complex patients for which NGDC providers need additional support through the practice's care management team, as well as patients in shared-savings and clinically integrated network arrangements. As part of this program, NGDC is also able to review claims data from payers to help identify when gaps in care have been closed by another provider outside its network. Access to a community health exchange is also utilized to help ensure NGDC is aware of the full spectrum of care provided to their patients.   

With a comprehensive service line that encompasses primary care and endocrinology, as well as diabetes education and nutrition, care for patients with diabetes is a major area of focus for NGDC. Through the PHM platform, care coordinators can look at the practice's entire diabetic population on one screen, and in just a couple of clicks they can risk-stratify that data by A1c value, number of care opportunities, or other metrics that allow them to quickly and easily identify outliers, and then engage with those patients. While control of the patient's diabetes may be the initial prompt to engage with the patient, the overall objective is one that focuses on the overall health of each patient.

As NGDC approaches its one-year anniversary on the PHM platform, and it recorded three top successes:

  • More than 29,000 patients were identified to have at least one care gap
  • More than 15,000 patients were proactively contacted via outreach related to their care opportunities
  • Successful closing of care gaps, with improvements particularly in chronic condition follow-up care, wellness visits, preventive screenings and vaccinations

How a small organization uses population health initiatives: Next page

The small: Charleston Internal Medicine, West Virginia

By Terry Coleman, administrative director, Charleston Internal Medicine

West Virginia-based Charleston Internal Medicine, CIM, is an independent practice with six physicians and two mid-level providers.  The providers pride themselves on the personal touch they bring to patients despite seeing 110-140 of them per day. Its use of PHM technology was the result of another initiative to improve care.

CMS selected CIM in 2013 to participate in a three-year project to transform healthcare in the Charleston area into the "Medical Neighborhood" concept. Among the goals were to decrease costs, improve the health of the local population by 15 percent, improve the patient experience by 25 percent and work with other practices in the area that are not part of the project to incorporate them into the medical "neighborhood."

While CIM had done proactive patient outreach to patients who were due for a wellness visit in the past, it was a manual and sporadic effort that involved printing letters, stuffing them into envelopes and mailing them.

As part of the CMS Neighborhood program, CIM gained access to an advanced PHM platform that became a game-changer. Rather than running a report in the EHR and reaching out to patients when the small staff had time, the technology now allows CIM to run three automated daily outreach campaigns, primarily using email. The campaigns include reminders for wellness visits, reminders to have lab tests performed after orders have been issued, and a campaign specifically targeted for diabetes care. CIM also runs other campaigns on an as-needed basis. In all, more than 7,600 communications were sent to more than 3,700 patients for various appointments.

Once patients are in the office, the PHM technology creates a care-gap list by patient and provider. This list makes it easy for physicians to discuss patient needs during office visits, helping CIM close more of those gaps.

Despite using only a small percentage of the PHM platform's capabilities, CIM saw outstanding results.

Between January and December 2014:

  • Wellness visits for CIM's overall population were greater than 80 percent
  • 82 percent of the 65+ population had annual wellness exams
  • Adolescent wellness visits increased by 146 percent
  • Breast cancer screening increased from 42 to 49 percent
  • Cervical cancer screening increased from 32 to 49 percent
  • Colorectal cancer screening increased from 34 to 64 percent
  • The number of unfulfilled lab orders dropped dramatically

Two additional benefits from using the PHM platform include helping CIM achieve Level 3 PCMH status, and assisting the organization as it becomes part of an ACO. Management says CIM wouldn't be as well positioned for success without the PHM platform.