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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40,000 Covered Lives: Improving Performance on ACO MSSP Metrics

The U.S. healthcare system is the most expensive in the world, but data consistently shows the U.S. underperforming relative to other countries on most dimensions of performance. The Centers for Medicare & Medicaid Services’ (CMS’s) accountable care organization (ACO) model is aimed at addressing that issue by offering financial incentives for providers to improve the health of populations and reduce costs through greater efficiencies and a focus on preventive care.

Mission Health formed a Medicare Shared Savings Program (MSSP) ACO called Mission Health Partners (MHP), which is responsible for 40,000 patient lives. MHP knew that its manual approach to data collection and reporting would not be sufficient for the required ACO quality metrics. By leveraging a previously implemented enterprise data warehouse platform and implementing an ACO MSSP analytics application, MHP was able to automate the processes of data-gathering and analysis and align the data with ACO quality reporting measures. The visibility and transparency of near real-time, online performance data coupled with focused process improvement has resulted in subsequent improvement in all 33 of the ACO performance metrics. Specifically, improvements have included:

  • 9.6 percent increase in compliance over all reported ACO metrics, with 23,000 more patients receiving recommended treatment or screenings.
  • 98.9 percent of eligible patients received screenings for clinical depression and follow up.
  • 40 percent increase in number of patients receiving any cancer screening; 46 percent improvement in the number of patients receiving colorectal cancer screening.
  • 456 percent increase in the number of patients getting fall risk screening.
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How Partners HealthCare is Managing Costs in the Emerging At-Risk Environment

In order to thrive in an ever-increasing risk-based contracting environment, accountable care organizations like Partners HealthCare need to deliver high-quality, safe care with minimal risk. Integrated data that reveals cost reduction and care improvement opportunities are necessary to be successful in a risk-based environment, and has historically been fragmented and limited in interoperability in healthcare organizations. To merge, house, and analyze the necessary financial, operational, and clinical data required for risk-based contracting, Partners deployed a late-binding enterprise data warehouse (EDW) and population health management analytics. The EDW and analytics applications are making information accessible to managers as soon as it is released, along with enhanced visualizations that enable data-driven insights. In addition, the analytics application is helping to drive physician awareness and engagement in understanding and managing cost trends.

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How Partners HealthCare is Leveraging Episode-Based Data to Improve Care Delivery

U.S. healthcare is shifting from procedure and visit approaches to a longitudinal view of patient care. The Centers for Medicare & Medicaid Services (CMS) is supporting this change with their “Bundled Payments for Care Improvement Initiative.” Under the initiative, healthcare organizations enter into payments arrangements with financial and performance accountability for 48 episodes of care. This requires health organizations to integrate data from a combination of sources in order to identify the bundles with the highest costs and the sources of variation. Learn how Partners HealthCare, an Integrated Healthcare Delivery System and ACO, successfully integrated hospital, provider, and claims information for the first time—and how they can now easily evaluate and compare clinical and financial performance for the 48 CMS episodes of care.

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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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Improving Healthcare Performance through Analytics and Cultural Transformation: One Healthcare Organization’s Journey

OSF HealthCare, a pioneer accountable care organization (ACO), was looking to deliver superior clinical outcomes, improve the patient experience, and enhance the affordability and sustainability of its services. OSF’s leaders recognized that to effectively achieve these goals, they needed to reinvent the organization’s performance improvement measurement and reporting system. In addition to deploying new analytics technology, OSF knew they needed to drive a cultural shift throughout the organization to embrace a data-empowered system. By engaging leadership, aligning the initiative with business strategies, and building data-driven clinical and operational improvement teams, OSF was able to save $9-12 million over three years—through both process improvement and cost avoidance. OSF also drove clinical performance improvements in key areas including heart failure and palliative care.

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How an ACO Provides and Arranges for the Best Patient Care Using Clinical and Operational Analytics

Crystal Run Healthcare—a physician-led Accountable Care Organization (ACO) and one of the first ACOs to participate in the Medicare Shared Savings Program—is experiencing the long-anticipated shift toward more value-based reimbursement.  To ensure financial stability as they assume more risk, Crystal Run is implementing a strategy focused on rapid growth and aligning physician reimbursement with favorable patient outcomes. To effectively execute on this strategy they knew they needed to become more data-driven.  Learn how this ACO is using advanced analytics to execute on their population management and growth strategies with a focus on continuous improvement in the following areas: 1) Ensuring patient care aligns with evidence based practices, 2) reducing clinical variation, 3) enhancing operational efficiency, analyzing data from a “single source of truth” integrated from their EMR, billing, costing, patient satisfaction and other operational system, and 5) making “self-service analytics” available to decision-makers to decrease time to decision.

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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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Other Content in Accountable Care

Posts

Understanding Risk Stratification, Comorbidities, and the Future of Healthcare

Risk stratification is essential to effective population health management. To know which patients require what level of care, a platform for separating patients into high-risk, low-risk, and rising-risk is necessary. Several methods for stratifying a population by risk include: Hierarchical Condition Categories (HCCs), Adjusted Clinical Groups (ACG), Elder Risk Assessment (ERA), Chronic Comorbidity Count (CCC), Minnesota Tiering, and Charlson Comorbidity Measure. At Health Catalyst, we use an analytics application called the Risk Model Analyzer to stratify patients into risk categories. This becomes a powerful tool for filtering populations to find higher-risk patients.

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Why Pioneer ACOs Are Disappearing and 3 Trends to Expect from the Exodus

Over half the Pioneer ACOs have dropped from the program in the last four years, despite achieving $304 million in savings, and fifty percent of the participating ACOs receiving shared savings reimbursements. Why the exodus? Overutilization and inconsistent performance benchmarking and attribution hindered the ability of many participants to achieve success. The overall impact of the program, however, has been a positive one for value-based care. In the next 3-5 years, providers and health systems will bear more of the financial risk of the populations they serve. The proliferation of data, and the tools to analyze and exchange it, will be critical to the long-term success of value-based care.

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A Guide to Governing Healthcare Claims Data Successfully: Lessons from OSF HealthCare

OSF HealthCare has committed that 75 percent of its primary care patient will be part of a value-based program by 2020. The organization’s leaders knew that success depended on how well they managed their data and decided to build a data warehouse in-house. They recognized that beneficiary claims data was essential to understanding their population better. To get that claims data, however, was no easy task. This required patient matching through master data management and getting buy-in from leaders and physicians throughout the health system. Then, they prioritize where to start efforts using the 80/20 rule and using that as a guide, loaded the claims data.

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5 Ways to Mitigate ACO Risk Using Analytics

Many healthcare organizations seem to have been in perpetual pilot stage while experimenting with value-based payment models. Healthcare organizations are focusing their efforts in two primary areas: developing the skills to successfully manage at-risk contracts and, preparing for the considerable business and care delivery transformation necessary for true population health management. But what are the foundational competencies needed to take on risk?  Healthcare organizations should consider the following 5 key areas:  1) at-risk contract management, 2) network management, 3) care management, 4) performance monitoring, and 5) improvement prioritization.  The value of analytics in each of these competency areas is to prioritize limited resources on the highest impact area.

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Data Management and Healthcare: Why Databases and EMRs Don’t Make the Cut on Their Own

Healthcare organizations preparing for the value-based payment model shift have found their internal resources pushed to the limit. Often, in an attempt to address regulatory timetables, systems will use point solutions rather than move toward a long-term strategy of developing robust clinical analytics. If an organization is using their EHR for analytics, they will soon discover that these built-in analytics packages cannot help them identify opportunities for cost effectiveness and clinical best practices. Sophisticated data management and healthcare analytics solutions, however, can provide leaders with the integrated clinical, financial, and patient satisfaction data they need to transform their systems into data-driven enterprises.

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Webinars

Accountable Care Transformation: The 4 Building Blocks of Population Health Management (Webinar)

Unlike few can do, Dr. David Burton has simplified these complex topics into a simple construct of four population health management building blocks. By acquiring proficiency in each of these four dimensions, healthcare delivery systems can create an asset which can be marketed to various types of governmental and commercial payers, which sponsor health benefit plans and offer shared accountability contracts (i.e. accountable care) into which these population health management sponsors can enter.

The key learning points of the webinar include:

  • The four building blocks of population health management (provider network, population(s), quality/safety outcomes, and cost outcomes)
  • The central role patient registries play in success in population health management
  • Pragmatic tools and methodologies to help healthcare delivery systems become proficient in each of the four dimensions of the framework
  • A discussion of the categories of governmental and commercial sponsors of shared accountability solutions, including the potential impact of the shift from defined benefit to defined contribution health benefit programs
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Principles and Priorities of Accountable Care Transformation (Webinar)

Facing the most sweeping payment transformation in history, healthcare systems are balancing two competing mandates:  build the competencies needed to succeed under value-based payment models while remaining financially viable in the current fee-for-service landscape. Across the next decade, changing payment models will drive a fundamental transformation in care delivery, emphasizing dramatically lower costs and improvements in quality. While this final destination is clear, today’s health care leaders face high stakes and a great deal of uncertainty as they architect the path for their organizations’ survival and success not only under value-based payment, but—critically—during the transition period.

Join Marie Dunn, Director of Analytics, as she outlines the key near-term priorities for health care organizations transitioning to value-based payment models, with a particular focus on the importance of leveraging data to drive effective decision making. She will also use Health Catalyst solutions to demonstrate these principles.

Marie will cover:

  • State of the transition from fee-for-service to value-based payment models
  • Near-term priorities for organizations looking to build the competencies to successfully manage at-risk contracts, including:
    • At-risk contract management: monitor performance against contractual requirements and leverage data to drive payer negotiations.
    • Network management: reduce leakage and improve referral patterns and network composition.
    • Care management: focus care team efforts by leveraging data to identify the patients in greatest need of support.
    • Performance monitoring: identify opportunities to improve performance on quality measures, like the ACO quality measures.
  • Strategies for balancing near-term priorities with long-term efforts to drive care transformation across the delivery system
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Population Health Analytics: Improving Care One Patient at a Time

Population Health Analytics is about more than just identifying a group of patients. It involves helping physicians care for their patients as individuals, improving their own practice through evidence-based best practices, and enacting cultural change that results in better outcomes for entire populations. Population Health Analytics—with the capability to look at one patient at a time and one physician at a time—will enable providers and organizations to answer three important questions: 1) What best practices should I be doing with this population? 2) How well am I following these best practices with this population? And 3) How can I change to create better outcomes for this population? 

In addition to addressing these population health questions, please join Tom Burton, Co-Founder and Senior Vice President of Product Development, Health Catalyst, as he discusses Population Health Analytics and presents the Three Systems Model of Care Delivery. Tom will share Health Catalyst’s experiences and learning’s and why each system is essential to create long-term change and transform healthcare. 

Attendees of the webinar will:

  • Learn about the Three Systems Model of Care Delivery required for effective Population Health Analytics. Understand the issues that must be addressed at each stage in order to optimize care delivery.
  • Discover the role analytics play in enabling physicians to deliver better care to their patients leading to improved outcomes for an entire population of the patients.

In the future, healthcare executives with a solid Population Health Analytics system will be better prepared to deliver better outcomes and more efficient care. Both will be key for succeeding with payment models based on risk, value, and performance.

 

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An ACO Case Study: Quality Improvement in Healthcare

OSF HealthCare—one of the first Pioneer Accountable Care Organizations (ACOs)—has a strong history of providing outstanding quality improvement in healthcare within hospitals, clinics, home health and other health provider entities across Illinois. For ACOs to succeed under value-based care, it is critical that organizations effectively coordinate care in the effort to maximize quality and safety, while minimizing costs and waste. It is also imperative that ACOs understand patients’ needs and values and incorporate them into all health decisions. 

Please join Leslie Falk, Health Catalyst and the OSF team—recipient of the 2014 Illinois Hospital Association (IHA) Institute for Innovations in Care and Quality’s first annual Tim Philipp Award for Excellence in Palliative and End-of-Life Care—as they discuss how they leveraged technology and data to launch a community-wide supportive care initiative that has successfully maximized value for the populations they serve.

Attendees of the webinar will:

  • Learn how OSF is improving healthcare quality and delivering on the Triple Aim.
  • Explore innovative ways to improve care coordination.
  • Discover how technology-enabled solutions drives community, patient, and physician engagement.
  • Understand the benefit of a team approach to improving care coordination.
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Data-Driven Care: The Key to Accountable Care Delivery from a Physician Group Perspective

Hospitals, payers and physician groups alike are facing changes in healthcare that require their attention. These changes are a result of financial forces that are changing the ways healthcare services are paid, cost of care pressures, ever-changing patient population behaviors, improvements in the science of health care and federal regulations tied to incentives that are soon turning to penalties. Anyone in health care is grappling to understand these changes and chart their strategies to be prepared for the future.

The presenters have proven expertise developing their strategies to care for patients in an accountable care model using data to drive their strategies. The presenting organizations will talk through their strategy including their future expectations and early results using data to identify improvement opportunities and to shift the clinical approach to health care. In addition to strategy, they will share solutions and analytic applications critical to the current and future expected results of their strategy.

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