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Care Management Solutions Improve Sprint to Value

Data-driven decisions and analytics are critical for organizations and physician practices transitioning to value-based care, although many organizations struggle with measuring the effectiveness of these population health initiatives.

To obtain sophisticated, actionable analytics and automate processes, Acuitas Health deployed the Health Catalyst® Patient Intake and Care Coordination applications concurrent with beginning the implementation of the Health Catalyst Data Operating System (DOS™) platform.  Acuitas meets the needs of its customers through a sprint to value—going faster than the typical time to value. The concurrent implementation approach used in this roll out set the pace for that sprint to value. In less than 60 days, the organization successfully implemented these tools and began receiving value. Acuitas is now able to:

  • Collect discrete data, and begin enhancing the work of the integrated care management team in a user-friendly way.
  • Identify individual caseloads.
  • Instantly obtain a complete, comparative, real-time picture of caseloads across the team—this reporting took weeks to compile in the past.
  • Make data-driven decisions on how to improve outcomes.
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Capturing the Voice of the Patient: Using PROMs Improves Shared Decision Making

Healthcare suffers from an overabundance of metrics, many of which are used to determine payment in several federal healthcare programs. While these metrics are intended to improve the quality of care that patients receive across the country, they provide no insight into how disease and treatment impact patients’ daily lives.

Partners HealthCare recognized that while it had data for patient outcomes such as mortality and morbidity, and an abundance of data for process measures, it did not have data about patient symptoms, function, or quality of life. To improve care, the healthcare system needed to engage patients to understand the impact of treatment on how patient’s felt and functioned following treatment.

Partners implemented a patient-reported outcome measures (PROMs) survey program to collect this data. Partners now has several years of experience collecting PROMs and is gaining insight into how to successfully collect and use the information to improve shared decision making with patients and their providers.

  • Patients have completed nearly 300,000 questionnaires in more than 20 specialties and over 75 clinics at most of Partners’ hospitals.
  • Clinicians actively use this data to facilitate shared decision-making with their patients.
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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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