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On the Population Health and Cost Transformation Stage, Care Management is the Star

Joe’s story isn’t a unique one in the U.S. Having been admitted to the hospital five times in one month, Joe isn’t taking his medications and doesn’t exercise. In short, he struggles to follow his care plan.

The Care Management Show, an entertaining, interactive theatrical performance, demonstrates why health systems need to adopt innovative, data-driven approaches to care management that prevent patients from falling through the cracks by integrating all aspects of patient care:

Data integration.
Patient stratification and intake.
Care coordination.
Patient engagement.
Performance measurement.

Throughout the show, the audience witnesses how care management done right transforms not only Joe’s life, but also Millrock Hospital’s profitability. We see how health systems can leverage technology to engage their “Joes” to increase care plan adherence and, ultimately, improve patient outcomes.

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Michael Mastanduno, PhD Yannick Van Huele, PhD

Use ACE Scores in Machine Learning to Predict Disease Earlier and Improve Outcomes

The Adverse Childhood Experience (ACE) study conducted by the CDC and Kaiser Permanent showed a strong correlation between ACEs and negative health outcomes later in life (e.g., risky health behaviors, chronic health conditions, and early death). ACE scores help paint a more complete picture of a person’s health history—a more comprehensive data snapshot of the entire patient.

Given that ACE scores build better data sets and machine learning relies on high-quality data, health systems should incorporate these nutrient-rich data sources into their machine learning models to better predict negative health outcomes, allow for earlier interventions, and improve outcomes.

Healthcare machine learning is evolving to use ACE scores and lifestyle data (e.g., eating habits) to improve population health management.

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Care Management Part 2 – A Critical Component Of Effective Population Health

Care management plays a central role in the world of value-based reimbursements, at-risk contracts, and population health management. Such programs require high-touch and resource-intensive care as teams work to deliver on the substantial promise of delivering patient care improvements while reducing costs.

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Mergers, Acquisitions, And Partnerships: Dramatically Reducing IT Consolidation Expenses With A Data Operating System

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Clinically Meaningful Quality Metrics Improve the Provider Experience

Nearly half (46 percent) of all physicians report that they suffer from burnout, citing too many bureaucratic tasks as one reason. Providers want to find meaning in their work, and improvement on many current quality metrics do not predict better patient outcomes or experience of care. They are looking for tools to reduce their workload and improve their ability to provide excellent care, including having metrics and registries that are meaningful and informative.

Faced with the challenge of making quality measures meaningful, Partners HealthCare worked to redefine measures to be more relevant, create point-of-care registries to manage an all-payer population, created teams of Population Health Coordinators to support front-line teams in managing the registries, and used its analytics platform to monitor change and explore provider variation in order to improve quality. This resulted in:

85 percent of clinicians surveyed felt that the new metrics helped them take better care of their patients.
Quality improved at an unprecedented rate on an all-payer population 5 times bigger than the standard P4P population.
Near real-time measurement using clinical data eliminated months-long delays, while run charts and provider and clinic-comparison views turbo charged quality improvement.
125 percent increase in user adoption of the analytic tool (99 unique users, 674 unique sessions, and rising).

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Comprehensive Approach to CAUTI Prevention Leads to Dramatic Reduction in Infections

Despite being common, healthcare-associated infections are potentially deadly and carry a significant financial cost. Of healthcare associated infections, catheter-associated urinary tract infections (CAUTI) are one of the most common, despite most instances of CAUTI being preventable.

As CAUTI was determined to be one of the top five influential factors in the publicly report quality scores, Piedmont Healthcare looked to data for more visibility into factors that were contributing to CAUTI rate in an effort to permanently reduce the number of infections. By engaging staff for compliance with CAUTI prevention best practices, Piedmont has seen sustainable improvements.

Results:

50.2 percent relative reduction in CAUTI standardized infection ratio (SIR). This translates to 37 fewer patients with infections than expected.
6.7 percent relative improvement in insertion bundle compliance.
Maintenance bundle compliance improved dramatically, with nearly a three-fold increase in the percentage of patients receiving the maintenance bundle.

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