Population Health Program Shares Best Practices
Orlando—Moving away from fee-for-service arrangements to value-based care can be a daunting process, but one San Diego-based medical center shared valuable insights from their move to population health management in a session at the NAMCP forum.
Vicki DeBaca, DNS, RN, vice president of health and provider services, Sharp Rees-Stealy Medical Centers, outlined the medical center’s population health program, population management strat- egies, and ways to manage the clinical effectiveness of such programs during the session.
The Sharp Rees-Stealy Medical Centers is a multi-specialty medical group in San Diego that is home to 450 physicians and 300,000 active patients. It is estimated that the medical centers’ multiple locations have approximately 1 million visits per year. The organization designed a population healthcare management program as part of a clinical redesign to improve patient care. The program was implemented in 2011 to serve all patients.
“Internally we have recognized for a long time that the physician needed additional support to help manage the workload,” Ms. DeBaca said. “In addi- tion, we know that we want physicians and all staff working at the top of their license.”
The population health program, according to Ms. DeBaca, has 3 essential components: (1) population identification; (2) population management; and (3) measurement of its clinical effectiveness. To identify the population, the organization used clinical claims data to conduct data analytics and predictive modeling. Through this process, they were able to stratify patients into 1 of 4 tiers. Each tier had its own interventions based on patient needs. Tier 1, which made up about 60% of patients, included patients identified as low severity who needed a preventative care reminder and annual wellness exams. The second tier, which accounted for 20% of the population, was designed for patients with moderate severity who would benefit from chronic disease programs and the implementation of evidence-based guidelines. Tier 3, which included 15% of the population, was designated for more severe patients who had chronic diseases, ≥2 hospitalizations, and needed more coordinated care and efforts to reduce hospitalization. The final tier included 5% of the most complex patients in the population.
“We specifically wanted to design a program to meet the needs of patients all along the continuum not just those in the hospital or those that come into a physician’s office,” Ms. DeBaca said.
The Sharp Rees-Stealy Medical Centers provide systemized care management to patients through care coordination, team engagement, and face-to-face care in the provider’s office or medical home. Patients also received support tools, such as biometric monitoring, to oversee their health at home. The organization also expanded their care settings by providing telehealth and home visits.
“Team care is critical because our medical group is responsible for the care of a large volume of patients with diverse needs. One of our goals was to optimize the physician role and allow other members of the care team to sup- port the patient needs as appropriate,” Ms. DeBaca said.
To aid in the management of a population healthcare management program, she suggested utilizing a common electronic health records (EHR) platform, creating workflows with automation and standardization, and optimizing the role of each team member to best apply their unique skill sets.
The Sharp Rees-Stealy Medical Centers also use a variety of tactics to promote patient engagement, whether it is through step-by-step wellness plans, patient specific education material, or medication adherence reporting. They have found these efforts to get patients invested produced significant improvements to the organization’s engagement rates.
As the population continues to increase its dependence on technology, Ms. DeBaca said technology devices, such as mobile health apps, can also be used to drive healthier behaviors in patients. According to data provided during the session, there are currently about 97,000 mobile health apps. Some of these apps can help patients track or monitor their health at home, something the majority of physicians would like their patients to do.
Once population management efforts have been put into place, the final stage of the process is measuring the clinical effectiveness of an organizations’ efforts. “With limited budgets and limited human resources it is important to assure that your programs are valuable and having the desired impact,” Ms. DeBaca said. “We try to develop specific metrics to measure not only individual team member performance and patient engagement rates, but also the health outcomes.”
The Sharp Rees-Stealy Medical Centers has developed different measurements to apply to different populations. For instance, in patients with congestive heart failure (CHF) the organization assesses hospital readmission rates.
The organization has already seen a drop in 30-day hospital readmission rates for CHF patients. The rate dropped from 10.55% in 2012 to 8.53% in 2013. They also saw a 3.5% improvement since 2011 in 30-day all cause senior readmission.
Ms. DeBaca concluded the session by sharing the lessons the organization has learned since the program was implemented in 2011. For instance, she said patient care workflows should be simple and centralized, team members should operate at the highest scope of their license, and technology should be integrated and used in the program. She also said the best way to engage a physician is to address practice variation.
Finally, she said it is important for health plans to use tools to measure ef- fectiveness and performance so they can demonstrate their return on investment or revise programs, if necessary.—Jill Sederstrom
