EXECUTIVE SUMMARY

A population health program uses quality metrics, case management, and other strategies to reduce healthcare costs and improve patients’ health outcomes.

• Patients are encouraged to call their primary care physicians during evening and weekend hours if they’re concerned about a health issue.

• The strategy addresses routine screenings, vaccinations, and chronic illnesses.

• An ambulatory quality council decides what to measure and sets goals.


Collecting population data and creating targeted case management strategies can help a healthcare organization improve patient health and reduce medical costs.

Case management often is geared toward achieving population health quality targets, but sometimes the best solution is to help a patient manage his or her minor medical complaints.

“There were many times when I’d get a call on a Sunday morning from a patient who had a little abdominal pain, and it didn’t sound too serious — just some acid reflux and heartburn,” says Rick Ludwig, MD, chief medical officer of value-based care at Providence St. Joseph Health in Renton, WA. “I’d suggest their spouse go to the drugstore and get some antacids and have them crush it up and take them. I’d call back in an hour or two and the pain was gone.”

Physicians can be part of the case management solution to overutilization of hospitals and EDs when they make themselves available to patients after hours.

In another example, Ludwig tells of speaking with patients in the evening about their skin rashes, bladder infections, and similarly minor concerns. “I suggest they see me the next day in the clinic, and I’ll see them at 8 a.m.,” he explains. “They know they can call me at 2 a.m. if their problem gets worse, so it’s not like they’re abandoned.”

Without that kind of telephone interaction, the patients might have headed to the ED worried that their problems were serious.

A population health strategy also addresses routine screenings, vaccinations, and chronic illnesses. “We have an electronic medical record that allows us to drill down to [data on] individual patients,” he says.

The population health approach helps patients, including employees, manage their chronic illnesses and ensures they receive appropriate health screenings.

“We talk with patients about the importance of quality care, and we want to keep our employees healthy, too,” says Linda Marzano, senior vice president of value-based care at Providence St. Joseph Health.

This is one aspect of how an accountable care organization (ACO) uses data and case management strategies to improve the health of its population.

“We have our own ACO, started in 2014,” says Barbara Fetty-Solders, RN, MN, CCM, manager of care management at Providence St. Joseph Health.

“We initially started with some direct contracting with employers in our area, and we have continued to expand our risk-based contracts, mostly with payers,” Fetty-Solders says. “We have almost 800,000 lives that are in some sort of risk contract.”

The organization collects Healthcare Effectiveness Data and Information Set (HEDIS) measures and sets targets to improve population health over time, she says.

“Each year, our regions are expected to improve their existing quality measures by a certain percentage,” she adds.

Hospital utilization is improved, but work on the quality measures continues, she says. “We’re not quite where the goal is yet.”

An ambulatory quality council (AQC), which consists of medical leaders and other stakeholders, decides what to measure and sets goals, Ludwig says.

“That group looks at where we are for each measure and sets goals for each year,” he explains. “The ultimate goal is to hit the 75th percentile for national benchmarks by 2020.”

This goal already has been achieved for some measures. “In others, we’re far behind,” Ludwig says. “We look at 2020 and do the math to see what [data point] we have to hit each year in order to get there.”

Anecdotal evidence and data suggest the program is working. For instance, a pilot program titled “Call Us First” advertised the importance of calling an after-hours number before heading to the ED, Ludwig says.

“We engage patients in the clinic to call us before they make a decision to go into the ED,” he says. “They’ve reduced ED use by more than 5% in the pilot study, and we’re spreading this program this year to the rest of the organization.”

The program has cost-savings potential. “There’s no cost associated with the program,” Marzano says. “Our physicians take the after-hours calls for patients who call in with some kind of problem and want to talk with a doctor.”

The program didn’t result in more calls than physicians were able to handle, Ludwig notes. “It wasn’t an avalanche of need after hours by our patients.”

Physicians worry about taking more calls, but the pilot project showed that there wasn’t that much demand after normal clinic hours, he adds.

But those who do make the after-hours call need help or else they might head to the ED as their default. “It’s striking how many patients think when the clinic is closed, they’re on their own,” Ludwig says. “They just didn’t know that the point of getting a doctor is you have coverage. They’re surprised and delighted they have the ability to call someone.”

The program’s model is mixed. Some case managers are embedded in the clinic, and some provide phone support. Some are RNs, and still others are social workers, Marzano says.

Nurse case managers also call patients who have overutilized the ED and help them find a community primary care provider, Fetty-Solders says.

“We see what kinds of needs they have and why they keep returning to the emergency department,” she says. “We use community resources for referrals, and in our clinic, we have embedded, licensed social workers who can do counseling and we have psychiatrists who can help with diagnoses.”

The idea is to address any issues that affect their health and ED visits.

“The success of this program is teamwork and having good relationships with clinics and staff,” Marzano says. “It takes a team to manage these patients.”