CASE 1: POPULATION HEALTH MANAGEMENT IN ACTION Although the integration of patie
ID: 434313 • Letter: C
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CASE 1: POPULATION HEALTH MANAGEMENT IN ACTION
Although the integration of patient-centered medical homes and account able care organizations into the health system is still emerging— as are best practices and key learnings from these early efforts— there have been myriad examples demonstrating encouraging returns and improvement in quality of care. The Patient-Centered Primary Care Collaborative recently profiled several organizations that have adopted patient health management (PHM) tools and strategies to address the preventive and chronic care needs of their patient populations.
A pioneer in implementing medical home and accountable care initiatives, Bon Secours has dedicated itself to executing a sustainable care delivery model that is in alignment with health care reform across its providers and locations. Bon Secours’s transformation into an organization that embraces PHM is the result of a systematic strategy to reengineer primary care practices, integrate new technologies into care team workflows, and engage patients in their care. Bon Secours took a leap of faith in implementing these changes, acting on the belief that payers would come to them if they built a viable model. And payers did. The organization was selected as an early participant in the Medicare Shared Savings Program. It has also signed value-based contracts with two commercial payers— CIGNA and Anthem— and is in negotiations with several more. These contracts provide a financial mechanism to expand and scale the medical home initiative and support ACO models. This case study examines in more detail Bon Secours’s approach to position itself to achieve quality outcomes and financial success in the changing health care environment.
Bon Secours’s Care Team Model
The foundation of Bon Secours’s strategy for value-based care is its medical home initiative— the Advanced Medical Home Project. The project began as a pilot five years ago. Since that time, eleven practices have earned NCQA recognition as patient-centered medical homes. One of the most significant objectives of the Advanced Medical Home Project is to improve capacity— making it possible for care teams to double the size of their patient panel without overburdening themselves or sacrificing quality of care. At the heart of this medical home strategy is the effort to reengineer practices by creating high-performance physician-led care teams, which requires changes in workflow, new care coordination activities, and designed delegation of clinical responsibilities across the care team. To facilitate this process, Bon Secours has invested significantly in embedding care managers into the primary care team. These nurse navigators are registered nurses (RNs) who are either board-certified case managers or actively working toward certification.
Each nurse navigator is assigned a panel of approximately 150 high-risk patients. He or she cultivates a personal relationship with these patients, usually through repeated phone contacts. Although most outreach is tele phonic, navigators have the skill to assess which patients require face-to-face intervention. And because they are embedded in the practice, they can spend time with these patients doing assessments, care planning, and education.
Bon Secours’s eHealth Strategies
An important aspect of Bon Secours’s strategy is implementing health information technology that empowers the care team to efficiently manage the health of their populations. They consider this technology— standardized across the medical group— as the key to enable them to scale their system for value-based care. As a first step, Bon Secours implemented an EHR and all its modules in every practice within the system. This gave them a strong foundation for documenting care and accessing health records across the enterprise.
Risk stratification.
They were able to build a registry that could identify high-risk and high-utilization patients based on data such as number of medications or frequent visits to the emergency department. However, the organization recognized the need for a more robust, scalable registry that would drive efficient population health workflows in their practices and enable analytics and predictive modeling across multiple clinical conditions. Integrating their EHR with a PHM platform, Bon Secours is able to aggregate all source data into a population-wide registry that enables the organization to implement multiple quality-improvement programs simultaneously. The registry stratifies the population by risk— providing a total population view while enabling each care team to drill down to the data they need about cohorts and individual patients. The system enables care teams within the practice to monitor their patients’ health status and take action by delivering timely and appropriate care interventions. Because the system automates these interventions, care teams are able to communicate with many patients at once. Automated outreach.
A significant priority for Bon Secours has been preventing thirty-day readmissions. The medical group uses an automated outreach system to identify discharged patients, link them to a primary care provider (PCP), and pinpoint those who are at high risk for readmission. Flagged patients are then called within twenty-four to seventy-two hours to reinforce discharge instructions, make sure their medications are reconciled, and set up an appointment with the primary care team within five to ten days of discharge. Bon Secours will soon implement a readmissions solution to automate the process of calling discharged patients, asking them to complete a short assessment, and escalating cases as needed based on their feedback.
Personal health records.
Another strategy for patient engagement is activating patients on an electronic personal health record (PHR), which allows patients to view clinical results and communicate conveniently with their caregivers via e-mail. Bon Secours works to gain physician consensus on policies that drive the use of PHR: physicians agreed to allow automatic release of normal results to the PHR, but abnormal results are held for 24 hours to enable the care team to contact the patient. The organization is relying on physicians and staff members to get patients active on the PHR to help them sign up on the spot in the exam room.
Challenges and Lessons Learned
Gaining physician buy-in for reengineering practice workflow.
The concept of the care team can be difficult for some physicians because they see them selves as the clinician and the rest of the team as support staff members. To help physicians embrace the care team and delegate patient-care tasks, Bon Secours placed tremendous emphasis on physician education. The organization also allows physicians to adjust some of the standardized care team protocols to meet the needs of their practice, which fosters ownership of the process and assures physicians that they remain in control.
Paying for the transition to value-based care.
As mentioned previously, Bon Secours implemented its medical home model with the hope that payers would come to them if they built a viable program. CIGNA currently gives the organization a per-member per-month (PMPM) adjustment for care coordination. Anthem, the group’s biggest payer, pays a care coordination fee and will change to PMPM in the coming year. Several more commercial payers are lined up to sign contracts with the group. However, this payer involvement is a relatively new development. For the first few years of the project, Bon Secours shouldered the expense. The organization is now poised to reap the rewards of its investment. Bon Secours is also demonstrating significant progress managing its CIGNA population. In the first six months of their value-based contract, they have achieved a 27 percent reduction in readmissions and are $1.8 million below their projected spend. They have hit many of their care quality metrics and need to improve their gap-in-care metrics only slightly to achieve the index necessary to qualify for gain sharing with CIGNA— a development that will bring a projected annual savings of $4 million. Bon Secours’s mantra for the future is “health care without walls.” The organization is aggressively pursuing remote, noninvasive monitoring for highly acute case management. Their vision is to bring care outside the four walls of the hospital into the patient’s home using technology. They are operationalizing a geriatric medical home that will enable patients to age in place with home visits for preventive and acute management. They are also expanding their implementation of the PHM platform to include performance measurement at the group, site, and provider levels; feedback to providers on variance in care; and quality reporting. This added functionality for analytics and insight on the clinical and administrative levels will help the organization ensure that it is meeting the triple aim (to improve the patient experience of care, including quality and satisfaction; to improve the health of populations; and to reduce the per capita cost of health care).
Innovation Impact
• Thirty-day readmission rate for medical home patients was < 2 percent for two years.
• Patient engagement scores were in the 97th percentile.
• Patient outreach efforts generated approximately forty thousand unique patient visits for preventive, follow-up, or acute care, leading to $7 million increased revenue.
2. What is your assessment of the approach Bon Secours has taken in embracing its commitment to population health management by investigating in different IT capabilities? How useful are capabilities such as risk stratification, automated outreach, and PHRs in improving quality while managing costs? Are there other tools that could have been useful? If so, what are they? How might they be used?
(please read the case case study first and then answer the question with 250-350 words ) thank you
Explanation / Answer
Bon secours have been a Pioneer implementation of medical home and accountable care services. It has successfully introduce Technology within Healthcare but most important of all implemented a system of Management within Healthcare teams to ensure perfect cooperation and coordination resulting in maximum output without sacrificing quality of Healthcare provided. Excellent management models such as its Care Team model has also resulted in greatly enhancing the capacity of medical homes, while ensuring accountability appointment of nurse navigator who are adequately delegated with assessment of needs and required care of the patient which results in adequate customer satisfaction personal interaction. Adequate health strategies implemented through latest information technology within the Healthcare further enhances efficiency and performance of the team. It serves as a measure of performance within the entire system for value based care along with adequate documentation and easy access to all data to enable better efficiency and accurate diagnosis and treatment by all involved.
Optimal utilisation of Technology along with efficient data management and analysis system by integration of all existing platforms with latest available quality improvement programs, has resulted in the most efficient utilisation of data through accurate and quick care interventions facilitated through automation ensuring maximization of number of patients cared for due to the ability to communicate with multiple patients. Automated outreach which monitors the condition of patients post discharge, through an appointed primary care provider, to minimise readmission has been exceptionally successful. Please capabilities have proved to be exceptionally useful which is absolutely proved by a $7 million increase in revenue along with 40000 unique patient visits and a sharp decline in the readmission rate within 30 days of discharge to below 2% 42 years.
Thank you sir approach of Bon secours was highly commendable and ensure that the patients failed they were an important part of the Healthcare system. However, positions are the major backbone of the Healthcare industry and their involvement in Planning the management of the teams from the initial stages would have resulted in teams which are absolutely attuned to the process and flow of work. Given the absolutely exceptional system introduced within Healthcare management integrating Technology within Healthcare to a great extent in an absolutely efficient manner with strategic implementation, along with monitoring and control measures is a commendable task achieved by Bon secours. Any minor defects which though not clearly visible may exist within the system, seem immaterial in the face of its achievement of providing quality care with customer satisfaction while achieving reduction in cost.
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