Population Health

Success Stories

Health Catalyst

How Allina Engaged Clinicians and Analytics to Improve Influenza Vaccination Rate

Influenza, a contagious respiratory illness spread by droplets, can lead to hospitalization and even death. Millions of people get influenza each year, hundreds of thousands are hospitalized, and thousands to tens of thousands die from influenza related causes each year. The key to preventing a devastating outbreak is vaccinating enough people that an outbreak is unlikely.
When Allina Health identified that its own rates for influenza vaccination were lower than desired, the health system studied data gleaned from its EHR and an Analytics Platform from Health Catalyst, which includes a Late-Binding™ Enterprise Data Warehouse and broad suite of analytics applications, to understand its true current vaccination performance. The data revealed that changes were in order, which Allina put in place through clinician feedback, engagement, and education.
Results:

4.8 percentage point improvement in influenza vaccination rate, exceeding the Healthy People 2020 goals for vaccination.

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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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How Texas Children’s Turned Child Diabetes Management into a Community Cause

Patients with diabetes are at a high risk for infections and substantial complications, including the risk of death from infections. Further, social determinants in these patients’ communities have a tremendous influence on their health.
Texas Children’s Hospital, ranked as one of the top four Best Children’s Hospitals by U.S. News & World Report, recognized that there were gaps in diabetes care coordination in the community—where the majority of a child’s diabetes management takes place. The hospital initiated a coordinated community response, aided with an analytics platform, which is setting the standard for community management of pediatric diabetes.
Results

4 percent relative improvement in the percentage of patients with diabetes who received the influenza vaccine.
3 percent relative improvement in pediatric provider diabetes knowledge.
90 percent of patients now have individualized school packets developed and available in the EHR.

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Systematic Improvement of Diabetes Care in the Inpatient Setting

Texas Children’s Hospital is improving the care delivery of its patients with diabetes, one of the most common diseases in school-aged children. How? Powered by dedicated improvement teams and analytics, they have focused on order utilization, timeliness of IV and subcutaneous insulin administration, length of stay (LOS), establishing a diabetic care unit (DCU), educating core diabetic nurses (CDNs), frontline staff adoption, and more.
Care delivery improvements include the following:

94 percent of patients with diabetic ketoacidosis (DKA) are assigned to diabetic care unit.
17 percent relative increase in patients with DKA receiving an evidence-based evaluation and order sets.
19 percent relative increase in patients with DKA receiving IV insulin within one hour of order.
50 percentage point improvement in the percentage of patients transitioning to SubQ insulin in less than four hours after medical readiness.
44 percent relative decrease in LOS for patients with DKA.

 

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DKA Risk Prediction Tool Helps Reduce Hospitalizations

Each year, more than 12,700 pediatric patients are diagnosed with diabetic ketoacidosis (DKA), a life threatening complication of diabetes. Texas Children’s Hospital sought a way to accurately predict risk of DKA in time for care team members to intervene before these patients suffered a severe episode.
The health system ultimately formed a multidisciplinary high risk diabetes team to devise pre- and post-discharge strategies, and DKA risk prediction tools aided by the Health Catalyst Analytics Platform built using the Late-BindingTM Data Warehouse.
Results:

30.9 percent relative reduction in recurrent DKA admissions per fiscal year.
90 percent of all patients with new onset type 1 diabetes at the Medical Center Campus have a documented RIPGC in their medical chart.
100 percent of patients with type 1 diabetes have a risk index for DKA documented every 6 months.

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Improving Population Health for Children with Diabetes

Diabetes is the most common chronic illness for children living in developed countries. Leaders at Texas Children’s Hospital wanted to take a more data-driven approach to population health management for children with diabetes. They created a Care Process Team (CPT) to pursue outcomes improvements related to diabetic ketoacidosis (DKA) since data from the EDW revealed that 64% of diabetes patients discharged had this life-threatening condition.
After the CPT achieved their initial goal of improving care for patients admitted to the hospital with DKA, they set out to implement larger improvements that would benefit the entire population of diabetes patients.
By empowering CPT members, leveraging data to drive decisions, and implementing new interventions effectively, the Diabetes CPT members have improved population health for patients with diabetes across all settings of care. Below are a few of the most significant results.

44 percent relative decrease in LOS for patients with DKA.
30.9 percent relative reduction in recurrent DKA admissions per fiscal year.
34.4 percent relative improvement in the percentage of patients with diabetes who receive the influenza vaccine.

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Analytics Support the Delivery of Effective Diabetes Self-Management Education

Effectively educating pediatric and adolescent patients and families to self-manage diabetes is a critical part of diabetes care. Leaders at Texas Children’s Hospital, one of the top four children’s hospitals in the country, recognized that diabetes self-management education that incorporates national standards and empowers patients can improve clinical outcomes and quality of life. While diabetes education has always been important to Texas Children’s, the education provided to patients was varied, no organizational standards existed, and tracking the effectiveness was not possible.
To address these challenges, Texas Children’s created an Education Care Process Team (CPT) that focused on: developing a standard education curriculum based on national guidelines, creating consistent education materials, leveraging powerful analytics to identify potential learning gaps and customize patient goals, and investing in the professionals who deliver education.
As a result of these efforts, Texas Children’s achieved the following:

Implementation of a standard diabetes education curriculum.
100 percent of diabetes educators are now CDEs.
70.7 percent of patients with diabetes have had an education visit with a CDE, and the hospital is on track to achieve its goal of 80 percent within the year.

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Improving Diabetic Care in the Ambulatory Environment

Diabetes is the most common life-threatening, chronic illness in children who live in developed countries. With effective management of diabetes, children with diabetes can live long, healthy, and active lives.
Texas Children’s Hospital believes that diabetes patients and their families are most successful in managing their disease if they receive standardized, family-centered, multidisciplinary care in both inpatient and outpatient settings.
Texas Children’s created a new Clinic Care Process Team (CPT) which developed a comprehensive approach to standardizing diabetes care by automating best practice alerts that help clinicians recognize the need for testing, so they order labs more quickly.
Within one month of implementation Texas Children’s saw measurable improvements:

Screening percentages for each test improved to >80 percent.
28.2 percent relative improvement in the percentage of patients receiving recommended annual thyroid-stimulating hormone (TSH) testing, with current performance greater than 90 percent.
23 percent relative improvement in the percentage of patients receiving recommended annual lipid testing, with current performance greater than 90 percent.
54.1 percent relative improvement in the percentage of patients receiving annual retinal examinations, with current performance at 94 percent.
Patient satisfaction is on an upward trend.

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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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Data-Driven Approach to Improving Cardiovascular Care and Operations Leads to $75M in Improvements

Health spending in the United States is greater than the gross domestic product of most nations, and the costs for cardiovascular disease (CVD) and stroke care alone total $193.1 billion. CVD accounts for approximately one out of every three deaths in the U.S. and contributes to the shorter life expectancy of Americans. Thirty-five percent of CVD related deaths occur before the age of 75 years, and 19 percent before the age of 65.
Allina Health is a large integrated healthcare delivery network operating in Minnesota and western Wisconsin that includes three large cardiac centers. Due to the prevalence and mortality rate of CVD, leaders at Allina Health recognized that they needed to focus on cardiovascular health in order to truly impact the population health and patient outcomes of the communities they serve.
By leveraging real-time data from its enterprise data warehouse (EDW), Allina Health effectively identified and addressed clinical practice variation and operational issues affecting cardiovascular care and costs. In doing so, the health system realized more than $75 million in performance enhancement savings and revenue increase over a four-year period by focusing on supply chain, lab test and blood utilization, clinical practice changes and clinical documentation improvement.
 

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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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How an IDS Standardized Care for Women While Increasing Market Share

One in three pregnant women give birth via cesarean section in the United States, which is more than double the rate the World Health Organization (WHO) recommends. And instead of decreasing, the overall C-section rate in Washington State increased 73 percent from 1996 to 2009. C-section rates are just one area of maternal care where our practice in the U.S. lags behind the science and knowledge of best practice. MultiCare Health System believes that all of its female patients should experience the same high-quality care across its integrated delivery system. The health of the next generation depends on it.
MultiCare recognized that it had to standardize care across its system to meet quality standards, improve its patients’ experiences and outcomes, and maintain its market share. The health system launched a Women’s Collaborative, the sole purpose of which was to improve clinical care and patient outcomes for women’s services systemwide.
By working with clinicians to implement standards of care, and using analytics to measure performance, the Women’s Collaborative achieved the following:

NTSV (low-risk, rst-time mother) C-section rate 9 percent less than the national average and already below the 2022 national goal of 23.9 percent
Six-point increase in market share for inpatient OB/GYN services
Improvements in care delivery:

63 percent reduction in episiotomy rate

11 percent reduction in SSI rate for C-sections
14 percent reduction in 3rd or 4th degree perineal laceration rate
Non medically indicated induction rate consistently less than a quarter of one percent
6.7 percent reduction in the percentage of abdominal hysterectomies

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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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Reduce Readmissions with Predictive Analytics and Process Redesign

With nearly 20 percent of elderly patients released from a hospital being readmitted within 30 days, Allina Health is focused on providing patients optimum care and support post discharge to minimize readmissions. Focusing on 30-day potentially preventable readmissions (PPRs) as its global outcome measurement, Allina Health used key clinical variables to derive the clinical relationships between hospitalizations that determine PPRs. It further built analytic capabilities to identify opportunities for improvement in care management and to test quality improvement ideas.
Allina Health’s multipronged solution included redesigning care management processes, implementing predictive analytics to identify at-risk patients, using analytics to measure the impact of its interventions, and educating patients, families, and clinicians.
These efforts are driving measurable improvements including: 10.3 percent overall reduction in PPRs, 27 percent reduction in PPRs for patients with clinic follow-up within 5 days, and $3.7 million reduction in variable costs due to avoided readmissions.

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Calculating the ROI of Diabetes Care Improvement

Texas Children’s Hospital has dedicated itself not only to successfully improving diabetes mellitus (DM) outcomes, but also to developing a framework for measuring the ROI of its performance improvement efforts. Texas Children’s tackled its DM initiative with a combination of technology investments and new organizational models, including an enterprise data warehouse (EDW) and analytics platform, a clinical care process team model for improving the quality and cost of care, and a diabetic care unit (DCU) staffed by a highly specialized, highly trained group of providers. Health system leaders also worked with the business school at Rice University to develop a model for measuring ROI that focused on easily quantifiable drivers. The results of this effort include substantially improved quality of care for DM patients, an increase in net revenue by a projected $232,000 annually, and an estimated ROI of 53 percent.

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Nationally Recognized Transitional Rehabilitation Program’s Strategies

Serving patients with special needs, such as traumatic injury or multiple high acuity co-morbidities, is a costly and complex endeavor. Allina Health’s Transitional Rehabilitation Program (TRP) tackled both of these realities head-on—resulting in cost savings while helping this vulnerable patient population achieve a higher quality of life.
Recognizing the need for high-quality data that could prove the TRP’s value to its patients and community, Allina implemented analytics that enabled it to track and report outcomes and costs, demonstrate value, and generate savings for the health system and the community.
The initiative has reaped wide-ranging results in patient improvements and cost savings including saving health systems and communities $3.2 million over a one-year period, 20 percent greater success than traditional skilled nursing facilities in discharging patients to home and community, 20 percent improvement in impairment in brain injury patients (MPAI-4), and 84 percent improvement in spinal cord independence measure (SCIM).

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Care Management Strategy Improves Lives of Stroke Patients

Stroke is a leading cause of hospitalizations among elderly often resulting in serious long-term disability, readmissions (up to 27% are readmitted to the hospital in year one), or secondary stroke. Allina Health’s Courage Kenny Rehabilitation Institute (CKRI) had deployed a successful care coordination model for other complicated, high-risk populations that it was confident would help stroke patients, as well.
CKRI created a holistic program for stroke patients that delivers comprehensive, seamless care across inpatient, outpatient and support services. A data warehouse and analytics platform merges data across the care continuum, and enables Allina to target high-risk stroke patients for coordinated care, track their progress and measure their outcomes.
Within a year, Allina was able to prove the value of this new care model for stroke by realizing $350,000 in cost savings and, most importantly, through actual lives saved and improved.

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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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One Healthcare System’s Effective Strategy to Improve Pneumonia Outcomes

MultiCare Health System, an IDS serving communities throughout Washington State, recently undertook an initiative to improve the care of, cost of, and experience for pneumonia patients. This initiative included the building of evidenced-based order sets (and driving their adoption), assigning a team of social workers called “personal health partners” to research and improve patient follow-up and communication, and deploying an analytics application to provide near real-time feedback on compliance and performance while offering a single view of patient-specific data across multiple visits and care settings, such as medication and readmission histories. Through these efforts, MultiCare has realized significant outcome improvements including reducing pneumonia readmissions by 23 percent, a 28 percent reduction in mortality rate, a 2 percent decrease in LOS, and a 6.4 percent reduction in average variable cost per patient.

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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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Patient Identification and Matching—An Essential Element of Using an Enterprise Data Warehouse to Manage Population Health

In a healthcare industry transitioning to value-based reimbursement and population health management (PHM), matching patients accurately to their care events across multiple sites of care and sources of information is becoming ever more important. Being able to accurately track utilization of services for a particular patient, patient population, or provider is fundamental to the strategies underlying effective population health management. Partners HealthCare developed an effective patient matching solution for more than 10.5 million patients achieving a 20 percent improvement in patient matching accuracy and a 96-99 percent high-risk patient matching rate. This has allowed the organization to accurately “flag” high risk patient populations and better manage risk under risk-based contracts.

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Using Advanced Analytics to Manage Population Health in Primary Care Clinics

The need to effectively manage the health of populations is largely driven by the fact that 5 percent of the population accounts for 50 percent of healthcare costs. Being able to identify these patients, provide high-quality care and reduce their utilization is a pressing goal for many of today’s primary care providers (PCPs). Learn how this healthcare organization used a healthcare enterprise data warehouse and analytics to better manage their individual patients and patient population, integrate regulatory and performance reporting, and allow PCPs to spend more time with patients and less time collecting data.

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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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