New York-based Northwell Health has been an early adopter of population health and leveraged technology to improve patient and provider experiences, as well as the health of the community, while reducing the cost of care. Those investments, along with more emphasis on primary care, are paying off with significant reductions in readmissions and ER visits among the large footprint it serves.
To achieve the Institute for Health Improvement’s Quadruple AIM, Northwell Health has made key investments in digitalization and connectivity. Northwell has adopted telehealth and patient monitoring programs with emphasis on primary care to improve access to affordable care. Additionally, care providers now consider patients’ clinical, behavioral as well as social needs in developing care plans. This Total Health approach requires a strong IT backbone to support population health initiatives key to Northwell’s continued success.
“We have to use a variety of resources to find the social determinants of health that are preventing people from getting access to care. We strive towards reducing the need for expensive acute care by engaging patients to do better self-management of care by providing them healthy lifestyle coaching,” said Simita Mishra, PhD, the population health Informatics leader within Information Services at Northwell. “By providing an enhanced level of primary care, we can keep the patient from becoming an inpatient.”
Emphasizing primary care to build greater engagement
Among Northwell strategic goals tied to Quadruple AIM are:
- Redesigning how primary care services are structured to treat more patients before they become severely ill and require hospitalization.
- Improving chronic disease prevention and healthy living through more patient engagement tools supported on a cost-controlled platform.
- Integrating systems to accommodate more patient centric solutions.
- Developing greater employee engagement throughout the health system so that everyone – not just frontline caregivers – is empowered to improve the patient experience.
- Shifting from being seen as a healthcare organization to a community-based system through more community partnerships.
“All of this is not possible unless you have a paradigm shift as it relates to how you take care of the patient,” said Mishra, who spoke on Northwell’s tobacco cessation program information intervention at the HIMSS19 Global Conference & Exhibition in February. “This involves a more holistic look at patient care focusing on the concept of Total Health.”
Prioritizing tech investments in data and connectivity
To achieve greater patient outreach and engagement, Northwell is focused on data – collecting, staging and analyzing data sets to gain insights and make decisions.
“Without accurate data we could not drive any of these initiatives or know where to invest,” she explained. “That’s why it’s important that data be validated and analyzed to be processed correctly and made actionable.”
Beyond data, Northwell also is building or buying digital products to:
- Improve connectivity across the continuum of care so there’s reliable service regardless of which hospital or practice someone visits.
- Interact with health information exchanges key to the organization’s population health programs.
- Raise patients’ and their families’ engagement levels through tools that promote personal health management.
- Improve patient experience by use of digital technology as well as human touch.
- Expand remote care and home-monitoring options so potential health issues are detected before they become catastrophic.
- Integrate with community organizations’ IT systems through improved interoperability. This makes for more seamless service when a patient is referred to a provider outside of the Northwell health system.
Promising early results in readmission and ER visit drops
Northwell is among the recipients of a five-year state grant with the overarching goal to reduce avoidable hospital admissions by 25 percent statewide. Now in its final full year, current trends show all statewide grant participants are on track to collectively reduce readmissions by 33 percent and see a 25 percent drop in ER visits.
“It’s encouraging to see positive results,” Mishra noted. “And I’m cautiously optimistic as we continue down this path.”
What Mishra is more openly excited by is Northwell’s cultural shift to more holistic patient care. There is also more reliance on data tied to population health, thanks to strategic investments in network connectivity, predictive modeling algorithms, analytics infrastructure, telehealth and home-monitoring programs, and overcoming interoperability issues.
She recommends other healthcare organizations ready to make a similar shift, to invest first in data to determine what solutions that enhance both the quality of care delivery and patient experience. “Patient empowerment and patient engagement tools are no longer dispensable,” Mishra said. “They are part and parcel of any organization trying to not only remain ahead of the curve but remain competitive in today’s healthcare landscape.”
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