Analytics with social determinants drives millions in value-based savings at Carilion

Carilion Clinic has been on a path toward value-based care for more than a decade, but staff realized they needed more support in gaining better insights into their patient population.
By Bill Siwicki
01:07 PM

Carilion Clinic in Virginia has been on a path toward value-based care for more than a decade and has built much of the clinical infrastructure needed to best meet its patients' needs. And although it had a certain level of analytics maturity, staff realized they needed more support in gaining better insights into their patient population.


"We didn't have a solution that could effectively risk-stratify and identify the most appropriate patients where intervention could improve their health outcome as well as lower costs," said Donna Littlepage, senior vice president, accountable care strategies, at Carilion Clinic.

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"This included support to analyze claims for cost and utilization trends across the population, such that we could target specific provider behaviors, where appropriate, and respond to utilization trends that were driving costs," she explained.


Littlepage and her team were reviewing technology from Evolent Health. They learned the vendor had strong performance management tools built into their care management platform and that this could strengthen the standardization of Carilion's processes, she said.

In the end, they decided that to be more successful in value-based care, they had to be able to identify various opportunities and then respond with appropriate interventions, she explained. In many cases, that meant also responding with more standardized clinical processes for staff, she added.


The market for analytics technology is fairly large. Vendors include 3M Health Information Systems, Acxiom, Berg Analytics, CareEvolution, Enli Health Intelligence, Health Catalyst, Informatica, Medecision, Optum, Oracle, Privacy Analytics, SAS Institute, SCIO Health Analytics and VigiLanz.


Evolent's Identifi system accesses claims and lab data across multiple populations and couples that with relevant data sources specific to socio-economic and social determinants of health. From there, the system's analytics engine produces specific insights or direction for patient care. This often takes the form of specific programs that are managed within the Identifi platform.

"Each program has specific workflows that enhance nurse productivity along with performance management," Littlepage said. "Whereas prior to Evolent we may have had variations in clinical operations, we now have a dedicated team of nurses that work within the same workflow, with the same data, and the same expected outcomes."

Carilion is in the process of taking relevant clinical information and integrating it into its workflow in multiple ways. First, it will highlight specific clinical analytics results within its Epic electronic health record, so caregivers know: 1) whether a patient has been selected for a specific care management program; 2) whether that patient has chosen to participate; and 3) the contact information for the patient's care coordinator.

"We're also in the process of using our risk adjustment process – another joint Carilion/Evolent Health creation – to provide patient analytics information to the clinical provider at the point of care; this should allow the clinician to be more efficient," she explained. "Last, we're working with Evolent to take patient-level data and integrate it into a pre-visit planning process."

Carilion believes the more the caregiver sees and understands the programs and the support he or she is providing their patients, the better the outcomes will be for everyone involved, Littlepage added.

Social determinants of health factor heavily into Carilion's value-based care efforts. Carilion is located in Southwest Virginia, a largely rural part of the country where social determinants of health are a significant factor in the utilization of healthcare resources.

"We believe that identifying those needs and proactively working with those members is critical to our success in value," Littlepage said. "That said, Evolent's analytics engine incorporates social determinants of health into its logic. In addition, both a behavioral health specialist and a social worker support those patients that are affected by social needs."

This allows Carilion's clinical team to run both a dedicated behavioral healthcare management program as well as support other behavioral or social needs across other clinical programs. Some of Carilion's best success stories come from the analytics-driven identification of these members and the organization's team that supports them, Littlepage said.


Carilion estimates it has saved millions through data-driven efforts. Carilion has not been able to pinpoint an exact number yet because the Centers for Medicare and Medicaid Services has yet to release the Next Generation ACO program results for 2017, which are expected to be publicly available by early 2019.

"The Next Generation ACO program was an opportunity to put our strategy to the test," Littlepage said. "We're proud to see it paid off, but we also learned a lot in the process. Through Evolent's support, we were able to better identify patients for appropriate care management while standardizing clinical care functions."

One goal of the organization's care management programs is to teach patients to manage their own chronic diseases. The analytics and care management platform allowed Carilion to optimize interventions that would be most successful for each patient.

"At the same time, we were able to impact specific utilization opportunities tied to post-acute care," she said. "The risk adjustment limit part of CMS's Next Generation program did not allow our ACO to receive full credit for the total risk of our population, so we had to focus twice as hard on care management in order to overcome those headwinds."

The tools and insights the analytics technology provided certainly supported that need, she added. And, when the analytics tools and insights were coupled with the talented Carilion team, the organization was able to see its successful partnership in action, she said.


"My advice would be to ensure that whatever analytics or IT tool you choose to use has both the ability to identify the right patients and provide performance management throughout the workflow of managing those identified patients," she advised. "You want an efficient workflow for the care management staff but also a way to know how well they are completing the work to achieve the desired results."

In other words, one can have the best analytics in the world but if one cannot quantitatively measure the clinical workflow of staff, then one will never be able to articulate why one was successful or identify areas of improvement, she added.

The data is only as good as how it is operationalized, and Carilion does not believe it would have been as successful if it did not have the capability to track and manage performance, she concluded.

Twitter: @SiwickiHealthIT
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