Population Health

Success Stories

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Machine Learning and Feature Selection for Population Health

Christiana Care Health System (CCHS) had used a machine learning model to inform population segmentation. The initial model used “black box” algorithms to predict risk that care managers didn’t have input on or understand. CCHS leaders and experts wanted an efficient model that they understood and trusted to predict 90-day inpatient admission. CCHS used a feature selection process to build the simplest model possible—and AI insight tools for selecting the best model, setting triggers for action, and explaining how the model worked.

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Medically Integrated Wellness Program Reduces Modifiable Risk Factors

Thibodaux Regional Medical Center conducted a community health needs assessment (CHNA) as part of its vision for a healthier community. The CHNA reinforced the hospital’s identified need for a data-driven, medically integrated wellness program designed to benefit the health of the community by educating, advocating, and supporting healthy lifestyle changes to address modifiable health risks. Using a wellness analytics application, Thibodaux Regional is able to track program outcomes.

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Data-Driven Workflow Improves Diabetes Education Program Effectiveness

To optimize the impact of its diabetes self-management education program, Allina Health enhanced its service model, aligning resources to proactively meet patient demand, while also maintaining high-quality clinical outcomes. Utilizing analytics in the redesign process has allowed Allina Health to understand patient needs better and monitor the impact of planned changes to the program on patient outcomes.

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Analytics Helps Population Health Coordinators to Better Treat Chronic Conditions

Improving the management of chronic diseases for patients is crucial for reducing expenses and improving health outcomes. Newton-Wellesley Hospital, a member of the Partners HealthCare system, adopted the population health coordinator role and utilized analytics to help identify variations in chronic disease management across practices and develop standardized best practices aimed at reducing costs through better outcomes for patients.

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Employer Health Plan Successfully Lowers Costs and Boosts Benefits

Offering a competitive healthcare plan for employees is a business essential, and a differentiator for organizations to attract top talent, but as healthcare costs continue to rise, employers are increasingly challenged to offer affordable employee healthcare with extensive benefits. Learn how Health Catalyst embraced self-insurance to take the management of its healthcare costs and benefit design into its own hands.

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Widespread Analytics Adoption Improves ACO Measure Performance

On an annual basis, ACOs are required to accurately report data that is used to assess quality performance which is also linked to eligibility to share in any savings generated. Read how Mission Health implemented a proactive approach to measure and evaluate performance, including widespread adoption of analytics and shared responsibility for ACO measure performance, enabling the organization to sustain and further improve its performance across multiple ACO measures.

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Opportunity Analysis Permits Successful Execution of At-Risk Contracts

Growth in the government payer mix and an increased cost burden to the commercial population, decreases in the private payer population, and programs like the Medicare Shared Services Program, have caused joint ventures, partnerships, and co-branding efforts, better known as at-risk contracts, between payers and providers to increase.
Allina Health has three Integrated Health Partnership (IHP) contracts, an accountable care model that incentivizes healthcare providers to take on more financial accountability for the cost of care for Medicaid patients, which cover approximately 90,000 members. To achieve success in its IHP contracts, and avoid losses, Allina Health needed to reduce healthcare costs while improving patient outcomes and experience.
Allina Health has integrated several data sources, including claims and developed the infrastructure required to perform opportunity analysis. Using data and analytics for opportunity analysis has given Allina Health insight into its IHP patient population, supporting the development of interventions to decrease the total cost of care and improve outcomes.

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Advancing Health Equity – Data Driven Strategies Reduce Health Inequities

Health equity means that everyone has an equal opportunity to live the healthiest life possible – this requires removing obstacles to health. The U.S. ranks last on nearly all measures of equity, as indicated by its large, disparities in health outcomes. Illness, disability, and death in the United States are more prevalent and more severe for minority groups. Health inequities persist in Minnesota as well, which motivated Allina Health to take targeted actions to reduce inequities.
Allina Health needed actionable data to identify disparities and to reduce these inequities. This came in the form of REAL (race, ethnicity, and language) data, which Allina Health analysts used to visualize how health outcomes vary by demographic characteristics including race, ethnicity, and language.  To understand the root causes of specific disparities as well as to identify solutions within their sphere of influence as a healthcare delivery system, Allina Health consulted the literature and also consulted patients, employees and community members. Then Allina Health created appropriate interventions based on this information.
As a result, Allina Health created an awareness of the health inequities among its patient populations, as well as effective approaches to breach the barriers that were preventing these patients from getting the care they needed. While much work remains in this long journey to achieve health equity, Allina Health has taken some significant steps forward, including:

Three percent relative improvement in colorectal cancer (CRC) screening rates for targeted populations, exceeding national CRC screening rates by more than ten percentage points.
REAL data embedded in dashboards and workflow to easily identify and monitor disparities.

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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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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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