Population health initiatives are proving to be among the most useful quality improvement resources for hospitals participating in accountable care organizations (ACOs). They’re leveraging the data from ACOs to target specific patient populations, improving care and reducing utilization.
A Texas hospital is applying lessons learned from its population health to improve the care of patients with chronic kidney disease. Some of the strategies involve helping clinicians recognize those patients so they can apply best practices to their care.
Houston Methodist Coordinated Care was the only ACO in the Houston market to take on downside risk in an ACO in the Medicare Shared Savings Program Track 3, notes Julia Andrieni, MD, vice president for population health and primary care at Houston Methodist. The risk of financial loss spurred the ACO to look for innovative methods to improve care.
One priority was working to prevent chronic kidney disease from progressing to end-stage renal disease. In their internal research, they realized that patients in stages 4 and 5 of chronic kidney disease weren’t getting follow-up by their primary care practitioners, and weren’t being referred in a timely manner to nephrologists, so they sometimes progressed to end-stage renal disease. Houston is trying to catch and disrupt those patients at a point where their disease progression can be slowed or disrupted.
“It was necessary for us to provide the best coordinated care,” she says. “Another key ingredient was physician engagement and we took a very patient-centric approach, which really resonated with physicians. We wanted to provide a service that had not been provided before across the continuum of care, whether that patient was in the physician’s office, the ED, the hospital, or a skilled nursing facility.”
That required clinicians and others in all those settings to be aware of the patient’s risks for conditions or events that could harm the patient and result in higher costs for the ACO, she explains. For patients in the kidney disease program, Houston Methodist used the risk banner in the electronic health record (EHR) that displays the patient’s risk scores for ED utilization, admissions, and complex care, as well as whether they are enrolled in a complex care or other targeted program.
“This helped the whole team — our primary care physicians, nurses, specialists, pharmacy, ED doctors, hospitalists — be on the same page about the risks for this patient and look for ways to manage this patient most effectively, and possibly differently than if we didn’t have that information,” Andrieni says.
The hospital highlighted the information in EHRs for all patients in the kidney disease program, in the hospital’s own EHR system but also in different EHRs used by private physicians, she explains.
“They were easily identified whenever they were in someone’s care, no matter where they were,” Andrieni says. “We needed to be able to communicate with each other across the continuum of care if we were going to improve the way these patients received care and make the downside risk acceptable in the ACO.”
Predictive analytics also were important.
You can’t provide the same care for each patient in a population health model, Andrieni explains, so it was important to know where to focus resources and effort for individual kidney disease patients.
Andrieni offers these lessons learned from the ACO experience and how Houston Methodist applied them in-house:
- align providers on the clinical risk of the target population;
- remember that the clinical mission comes first;
- financial impacts are the byproduct of high-quality, high-value care;
- find high-value actions that are aligned with the full panel;
- make requests clearly defined and directly actionable;
- impacting complex provider behaviors and decisions is unrealistic;
- empower, don’t command;
- ensure providers feel they are decision-makers in the process;
- providers should come to an agreement on clinical guidelines to truly drive behavior change.
Focus on Post-acute Care
The ACO experience showed Houston Methodist that it needed to better address the patient’s post-acute care experience, says Janice Finder, RN, MSN, director of population health and process improvement.
“Our patients take for granted that we are coordinating all of their care, and we needed to learn more about our partners to do that. We now have relationships in which a patient can go right into a skilled nursing facility from a doctor’s office, a one-night stay in the hospital, or from the emergency room, and very specific criteria will be used to get that individual patient the best care,” she says. “The whole goal is to get people to the right level of care, so we had to have nurses and care teams who first knew where these patients were and then were able to very quickly treat them and get them to the next level of care.”
That required good working relationships with the skilled nursing facilities and other partners, but Houston Methodist also realized the importance of working with the community. Population health initiatives are broad-ranging, and clinical excellence is not enough if the patient goes home and then deteriorates, Finder says.
“We wanted to get rid of all the barriers that were preventing people from getting the care that they needed with their primary care physician, so sometimes that means addressing a lack of food or transportation and sometimes it means getting to the know the patient on a deeper level so you can see what drives them,” Finder says. “Why are they not going to the doctor? What is their real goal for their health and how can you help them get there? Is it making it to their son’s wedding or their granddaughter’s graduation?”
One win-win for the physicians and the ACO was helping with home health.
“We knew from the data that we were an outlier with home healthcare, so we took the burden off the physicians to look at all the home health certifications,” Finder says.
The ACO took on the responsibility of reviewing home health providers, determining what the patient needed, and coordinating the care arrangements with the physicians. Because the ACO had connectivity with the physicians’ EHR systems, it could coordinate the home care arrangements with better long-term results and decreased administrative burden on the physicians.
Plan Early for Next Care Level
About 45% of the hospital’s patients go on to another level of care after discharge, so Houston Methodist adopted a strategy of early intervention, planning for that next level of care at the time of admission.
“That was the only way we could have a reasonable length of stay and have a good idea of what that patient’s needs were long-term. That requires a coordinated effort by nurses, social workers, and we also include a clinical pharmacist,” Finder says. “Medications are a big part of the program, ensuring not only that they have the right medications but that they can afford them. We may have to look at switching brands or helping them with access — whatever is required to make it easier for them to take the medications they need to take.”
Houston Methodist worked with Evolent Health, a company based in Arlington, VA, to analyze population health data and develop appropriate strategies. Finder points out that innovation in population health management is driven by data analysis, and implementing that innovation requires superior communication and coordination with healthcare providers.
“That is one thing that set us apart when we went out to discuss these initiatives with physicians. They are impressed with the level of communication and the layers of coordination that we have in place,” Finder says. “Better coordination of care across the spectrum is the key for improving the lives of these patients and seeing success for the hospital and the ACO.”
Deaconess Identifies Opportunities
Deaconess Health System in Evansville, IN, is leveraging the population health experience in multiple ways. Deaconess participated in MSSP Track 1 starting in 2012. It joined the Next Generation ACO in 2016, establishing financial incentives linked to performance, leadership training for physicians who typically spend all of their time practicing medicine, and a physician engagement strategy that included a governing board composed of practicing providers. (For more on how ACOs have led to hospital quality improvements, see Hospital Peer Review, December 2017, at: https://bit.ly/2pR1PlF.)
Also working with Evolent Health, the health system merged data from several systems, using predictive analysis to risk stratify the population and determine the appropriate care path for high-risk patients. Deaconess implemented a population health program to identify patients susceptible to avoidable conditions and implemented complex care and condition-specific programs targeting the sickest patients. Dedicated care advisors managed them for six months.
One of the biggest challenges was identifying the complex patients needing targeted attention, says Steven Etherton, DO, a Deaconess physician in Oakland City, IN, and a member of the Physician Advisory Council, which helps promote population health initiatives.
The data analysis helped identify users who were using a significant amount of dollars for their healthcare, and they were then placed in the complex care programs that could help predict future care needs, he explains.
Deaconess developed the Risk Adjustment Factor Clinical Initiative, which incorporated data on the identified patients and engaged physicians, encouraging a bi-directional flow of information between the Council and physicians, says Renee Michelle Galen, MD, also a Deaconess physician (in Newburgh, IN), and a member of the council.
One concern from physicians was making sure the program addressed those patients who were sicker and required more resources, fitting them into the shared risk model without compromising their care.
The health system implemented several quality improvement initiatives as a direct result of the population health experience in the ACO. A fairly new one involves making the ED more efficient, encouraging physicians to cooperate with best practices and common procedures.
“The program is tiered and the physicians or clinics have an option for how aggressive they want to be regarding this ED initiative. Some of the issues are as simple as having the appropriate message on your answering machine when a patient calls after hours, and it goes up in complexity to the physician committing to working late one day a week so patients can be seen instead of going to the emergency room,” Etherton explains. “They might even reach an agreement with an urgent care center to direct patients there if they can’t see the doctor and don’t have a true emergency.”
Varied Physicians on Council
Deaconess also is using different online scheduling options to improve access in the ED and other areas. The advisory council has smoothed over some of the most common challenges a health system encounters when trying to change established systems, Galen says, and the council’s effectiveness is due in part to the variety of its physicians. The council has many primary care physicians, but also physicians from several specialties, inpatient and outpatient, some who are Deaconess employees, and others who are affiliates. There also are representatives from administration.
“It’s kind of a different viewpoint from all the people sitting around the table when we talk about what is important to the institution to go forward and achieve these value-shared contracts. It’s important for the buy-in to have practicing physicians,” Etherton says. “As a practicing physician, we already have very busy, hectic days and we don’t want someone to add a burden to us when there is a way to do it without having to extend ourselves even more.”
The council meets about once a month and members discuss quality data, along with ideas for practice changes, explains Bradley Scheu, DO, a Deaconess physician in Newburgh, IN, and a member of the council.
“We’ll look at the data as a whole about quarterly for issues like colon screening, breast cancer screening, and emergency visits, looking at that data as a group to see if we can identify outliers and learn anything from those experiences,” Scheu says.
“Diabetic eye exams were a difficult quality metric for some of our physicians, so by looking at what some offices were doing with that we were able to create a document that we asked patients to take to their eye doctor and send back to the primary care doctor. It wasn’t that the eye doctors weren’t doing it, but we needed that information coming back to us to close the loop and meet that higher quality metric.”
Taking Data Local
The council also takes data down to the local level by grouping five to 10 physicians who practice in the same geographic area in a “pod” that meets every other month, Scheu says. An administrative representative shares quality metrics on a particular issue such as emergency visits, providing specific data on the individual physicians, their practices, the pod, and how they compare to the entire Deaconess network.
“This is information that would have been discussed at the council level and we might have discussed potential changes, but bringing it down to this level helps physicians feel that they’re getting an accurate picture of where they stand, rather than feeling lost in data that includes so many others who may be in different settings or dealing with different practice issues,” Scheu says. “It has been an important part of keeping physicians engaged and motivated to make meaningful changes and actually move the needle.”
Deaconess used to provide data with physician names attached, but it found that was counterproductive.
“They didn’t want to be put in the position of competing with each other, with their friends and colleagues. They’re fine with knowing where they stand, that their metrics are not as good as the practice or as some other physician, but they didn’t want to know that their peer down the hall was performing better and feel like we were putting them in direct competition and creating friction,” Scheu says.
“So we started showing the data blinded, so that I only know where I stand and how I rank relative to the five other people but not with their names attached,” he adds.
Scheu notes that providing that sort of data prompted improvements in colon cancer screening, without any financial incentive attached. Deaconess now provides a financial incentive.
Good Results Emerging
Deaconess is seeing decreased hospitalization for patients in the complex care program, and there have been decreased expenses with chronic kidney disease patients, Etherton says. The initial indications from the ED initiative also are promising, he says.
Etherton advises hospital quality leaders to be flexible and not expect every initiative derived from population health to yield substantial results. It is likely, however, that even the less successful initiatives will yield lessons that can be applied to new projects down the road, he says.
“As more and more of this data analysis occurs, we will find more areas of high utilization and ways to address those issues also. But it’s not all about the money,” Etherton says. “There is an advanced illness program that helps people in the end stage of their life, helping them with their advance directives, living wills — other things that can be overlooked at that stage of care. So it’s not just about the cost savings. It’s about quality of life also.”
- Julia Andrieni, MD, Vice President, Population Health and Primary Care, Houston Methodist. Phone: (713) 790-3311.
- Steven Etherton, DO, Deaconess Health System, Oakland City, IN. Phone: (812) 749-6187. Email: firstname.lastname@example.org.
- Janice Finder, RN, MSN, Director of Population Health and Process Improvement. Houston Methodist. Phone: (713) 790-3311.
- Renee Michelle Galen, MD, Deaconess Health System, Newburgh, IN. Phone: (812) 426-9700. Email: email@example.com.
- Bradley Scheu, DO, Deaconess Health System, Newburgh, IN. Phone: (812) 858-6244. Email: firstname.lastname@example.org.