Care Management & Patient Relationships

Success Stories

Enhancing Mental Health Care Transitions Reduces Unnecessary Costly Readmissions

Nationally, hospitalization for persons with mental health disorders has increased faster than hospitalization for any other condition. Of concern is the lack of bed space to intake these patients on a timely basis. In Minnesota, for example, more than 50 percent of available state psychiatric beds were closed between 2005 and 2010. Furthermore, readmission rates for patients with mood disorders is higher than any other mental health condition, with 15 percent readmitted within 30 days of hospital discharge and up to 22.4 percent of patients with schizophrenia being readmitted. While the average cost of a readmission in the U.S. is approximately $7,200, of greater concern is hospital readmission represents poor patient outcomes related to lack of adequate access to community mental health resources and challenges with adherence to care plans needed to prevent chronic relapse.
In response to these challenges, Allina Health put a new care transition process in place, redesigned workflow, and added key patient support roles. To measure the effectiveness of new interventions, Allina relied on the Health Catalyst Analytics Platform, which includes the Late-Binding™ Enterprise Data Warehouse and a broad suite of analytics applications.
Results:

27 percent relative reduction in potentially preventable readmission rate.
80 percent patient retention rate in established outpatient mental health services.

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Integrated Care Management – Improves Care and Population Health While Reducing Costs

One hundred thirty-three million Americans, 45 percent of the population, have at least one chronic disease. Chronic diseases are responsible for 7 of 10 deaths each year, killing more than 1.7 million Americans annually. Moreover, chronic disease accounts for 86 percent of our nation’s healthcare costs.
An integrated delivery system and an accountable care organization with two large academic medical centers and six community hospitals, Partners HealthCare is increasingly compensated for outcomes of care. Recognizing the need to more effectively manage its chronically ill patients, Partners implemented an integrated care management program (iCMP) to improve the outcomes of rising-risk patients and better manage treatment costs. The iCMP is a primary-care embedded, longitudinal care management program led by a nurse care manager working collaboratively with the primary care provider and care team.
The iCMP is contributing to Partners effective management of patients and financial success in at-risk contracts. In its Pilot Phase as a Medicare Demonstration Project, the program achieved the following results:

20 percent lower hospitalization rate per 1,000 patients.
13 percent lower rates of emergency department (ED) utilization.
25 percent relative difference in mortality.

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Care Management: A Critical Component of Effective Population Health Management

Unprecedented changes in the healthcare payment system have resulted in health organizations across the country investing in the pursuit of the Institute for Healthcare Improvement’s (IHI’s) Triple Aim to improve population health, improve patient experience and outcomes, and reduce costs per capita. Health organizations must develop effective population health management strategies, and they need the right data and analytics to inform their initiatives.
Once armed with the information to make data-driven decisions, leading healthcare providers are implementing care management programs, which have proven to be helpful mechanisms for achieving the Triple Aim. Many healthcare organizations have identified specific patient cohorts to monitor the impact of care management interventions on individual and population health outcomes.
Data-driven care management programs that target high-risk and rising-risk patients can achieve impressive results, including:

Up to 20 percent lower rates of hospitalization in mature care management programs.
Lower rates of emergency department utilization.
Decreased costs.

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Developing a Multilevel Approach to Improving Population Health

Heart attacks are the leading cause of death for both men and women in the United States, yet heart attacks are largely preventable through healthier lifestyles. Spurred on by this knowledge, New Ulm Medical Center, the Minneapolis Heart Institute Foundation, and the rural community of New Ulm, Minnesota, teamed up to create Hearts Beat Back: The Heart of New Ulm (HONU) Project. This population-based prevention demonstration project aims to reduce the number of heart attacks and heart disease risk factors among the New Ulm population.
Recognizing the complex web of personal, institutional, and societal factors that influence an individual’s heart-health behaviors, HONU leaders implemented a multilevel strategy spanning 10 years to improve the health of the entire population.
The HONU Project’s multilevel, data-driven approach has resulted in substantial changes in improving population health in New Ulm:

Significant improvements in blood pressure and cholesterol at the population level.

86 percent of residents now have blood pressure within the recommended range.
72 percent have LDL cholesterol within the recommended range.

Improvements are greater than changes seen in the national comparison population.

 

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A Care Model to Support the Needs of Medically Complex Patients

People with disabilities face daunting challenges in accessing basic healthcare. As a result, they frequently use hospitals and emergency rooms, and are four times as likely to be hospitalized compared to the general population.
Allina Health has deployed an effective “primary care medical home” model that gives patients with disabilities the care and support they need outside of the hospital setting. Key strategies of the model include assigning dedicated care coordinators to each patient; strengthening care coordination across the continuum of services; and an analytics platform from Health Catalyst to target opportunities for improvements and savings.
Allina’s data-driven efforts to strengthen care of patients with disabilities have made a clear and meaningful impact; most importantly, on patient outcomes. They have achieved: 30% reduction in hospitalizations and 66% reduction in hospitalization days; 79% reduction in 30-day readmissions days; significantly improved access to care; and saved $4.5 million over a one-year period.

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Innovative Approach to Rehabilitation Care Improves Patient Outcomes

Disability is one of the United States’ most important public health issues—with approximately 15 percent of citizens affected. Allina Health created The Courage Kenny Rehabilitation Institute (CKRI) to help people with disabilities, injuries, or complex medical conditions achieve the highest possible degree of health, functionality, and quality of life.
CKRI’s advanced model for rehabilitation care focuses on the whole person, one that looks beyond the medical to address vocational, social, and emotional needs. This collaborative model enables comprehensive and seamless care across the continuum while preparing the organization to operate in a value-based, at-risk environment. CKRI also implemented an analytics infrastructure to help focus its resources appropriately and to measure success.
This innovative approach has optimized patients’ quality of life with up to 76 percent reduction in hospitalizations and 53 percent reduction in ED visits – resulting in annual community cost savings of $11.2 M.

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Managing Half a Million Risk-Contracted Lives: Partners HealthCare Population Health Strategy

Population health management in a value-based model requires reengineering care delivery to provide higher quality of care at a lower cost. To address this challenge, organizations need to take a system-wide, strategic approach to defining their structures and processes. Learn how Partners Healthcare, an Integrated Healthcare Delivery System and ACO, developed and successfully implemented a strategic framework —guided by strong leadership and meticulous change management—for managing its half a million risk-contracted lives. The framework enables collaboration and aligns providers across the care continuum, using a unified set of performance targets for all contracts. The framework includes a robust analytics system that provides metrics to deliver the best patient care, while meeting the disparate requirements of multiple external contracts. Partners Healthcare has developed an internal performance framework that can serve as a population health management model for health systems throughout the United States.

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Quality Improvement in Healthcare: An ACO Palliative Care Case Study

Quality improvement in healthcare is essential for healthcare organizations as they transition to value-based care. Including palliative care in the planning and implementation of value-based care initiatives is more important than ever—especially for accountable care organizations (ACOs). This case study reviews the OSF Healthcare community-wide palliative care program and examines their key results: a) completion of 4300 advance care plans and engagement of more than 980 physician and community facilitators; b) leveraged a healthcare enterprise data warehouse (EDW) in a heterogeneous EHR environment; c) enabled data transparency at all levels through reporting and visualizations.

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