EXECUTIVE SUMMARY

Healthcare organizations collaborate on population health initiatives and the result is a quick improvement in clinical outcomes and patient satisfaction.

• The triple aim is to increase quality, improve access, and reduce costs.

• The effort first focused on Medi-Cal, California’s Medicaid program.

• Improving gaps in care was the first step.


As the healthcare industry moves from volume-based to value-based care, a key strategy in covering population health is to focus on communities, moving them toward affordability and better care delivery.

“Part of that strategy is if we can partner with providers in the communities and partner with payers around care delivery, then we can help fulfill the triple aim of increasing quality and access to healthcare while reducing costs,” says Jeff Conklin, FACHE, payer and network strategies executive at Adventist Health in Roseville, CA.

Case management work can result from these types of strategic relationships, as everyone’s interests are aligned to improve gaps in care.

Adventist Health West, representing Oregon, Washington, Hawaii, and California, has formed partnerships that extend the reach of its population health goals. One new partnership is with Oregon Health & Science University, an academic medical center in Portland.

In central California, Adventist Health has partnered with Health Net to serve the Medi-Cal population, which is California’s Medicaid population.

With partnerships throughout the health industry continuum, Adventist Health is better equipped to improve healthcare in its communities, Conklin says.

“We’re partnering with a number of payers, staying generic, to help both of us to grow and serve our communities,” he explains. “It’s early in our work, and we spent the last year and a half trying to get some of these launched; the early indicators are very positive.”

For example, outcomes from one small county show that the Healthcare Effectiveness Data and Information Set (HEDIS) scores went from the lowest in California to the highest in the state, Conklin says.

The HEDIS tool, from the National Committee for Quality Assurance (NCQA), is used by 90% of the nation’s health plans. It measures a combination of clinical performance scores and patient satisfaction, and it allows apples-to-apples comparisons. (For more information on HEDIS, visit: http://bit.ly/2GnkLna.)

“I’m personally very excited about what we were able to do as a team, by working across several organizations to address many issues, including clinical quality, operational, technical, and patient-facing opportunities for improvement,” says Dan M. Rhodes, network and market development executive of Adventist Health Plan.

The following are the three main steps in the population health collaboration:

1. Improve gaps in care.

The goal was to improve clinical results.

“We had a defined population and identified patients where they worked,” Conklin says.

The defined population included Medi-Cal patients. “We identified patients who needed care, and we worked with a rural health network and providers in the community to get patients into care,” Conklin says. “A medical team in the community was led by the medical director in that market and teams in rural health clinics and a team at Health Net.”

Health Net’s focus is on collaboration with provider organizations to enhance the overall patient experience and health outcomes, says Ramiro Zuniga, MD, MBA, FAAFP, regional medical director of medical affairs for Health Net.

“We work in close coordination to excel and improve quality of care and HEDIS measures for our members,” Zuniga says.

Together, they worked to identify each patient’s care gaps; for instance, whether the patient received necessary vaccines. If not, they’d ask the patient to come to a clinic for shots.

“We didn’t wait for patients to come into the clinic — we reached out where we knew there was a gap,” Conklin says.

“Adventist Health Plan worked in collaboration with our health plan sponsor and local medical offices to improve the quality of care provided to our members and patients,” says John Zweifler, regional medical director at Adventist Health Plan. “We met every two weeks to stay on task and address any issues that arose. We combined technical fixes to better capture HEDIS activity with point of care processes and systematic member outreach to close gaps in care.”

The collaboration worked: “Our collective efforts allowed us to move from the bottom to the top quartile of performance in just two years,” Zweifler says.

Following up on that success, Adventist is establishing similar projects in metro Portland, partnering with payers there, Conklin says. “We’re trying to do this across the geography that we serve,” he adds.

2. Improve data and document care episodes.

“We’ve set ourselves a goal that if we really believe our mission is to improve the health status of our communities, then we have to be in the top decile for quality care,” Conklin says. “We have to measure clinical performance very specifically.”

For instance, a healthcare organization should identify best practices for a particular measure and then close the gap between the actual performance and the best practice.

“We’re very rigorous with data,” Conklin says. “We think it’s very important to get pharmacy data, and that’s hard to do in a traditional, volume-based episodic model of care.”

HEDIS data make it possible to close gaps in care because they provide comparisons and show how a patient population is doing over time. Sharing clinical data helps to improve health status, he adds.

“It’s all about getting actionable clinical data in the hands of the caregiver at the point of care,” Conklin says. “If you’re in traditional, volume-based episodic model of care, then you’re not working on things to get clinical data changed that fast.”

3. Get data to payer(s).

“Make sure you get the data to the payer,” Conklin says.

For Adventist, the payer is Health Net and the population served was the Medi-Cal group. They exchanged electronic claims data, filing information with HEDIS.

“Once we saw a patient documented for care, we got the information on the record to document the claim, and that’s how data was transferred,” Conklin says. “We could see a comparison with their results.”

All three steps are necessary.

“My wife is a nurse, and she reminds me that if you didn’t document it, it didn’t happen,” Conklin says. “You have to document it, and then get the documentation out to the payer. You have to do all three successfully.”