Online health risk assessments (HRAs) can be used to help make patients aware of their health problems and to help care managers stratify their patient populations by health risk. This approach complements the primary risk stratification strategy, which relies on registry reports to classify patients based on clinical data.

Using Automation to Reach Patients

Provider organizations can use an automated process to generate health risk assessment data. Patients receive an e-mail inviting them to complete an HRA. When they click on a link, it takes them to the HRA on a website. After they answer the questions, the application automatically calculates scores for their risk factors and their willingness to change their health behavior.

Care managers can use this data in a variety of ways. For example, they can identify all patients with high-risk scores. They can also stratify the population as high, medium or low risk, with the assistance of registry reports, and use that classification as the basis for appropriate interventions.

Engaging Patients to Change Behavior

Care managers may also factor in each patient’s willingness to change. For example, if a patient has high blood pressure, is overweight and is an active smoker, but is not ready to change, the care manager might consider that patient for an online education program or might send a message inviting him or her to attend a motivational program offered by the healthcare system.

Learn More

Listen to a webinar about engaging patients using care automation within an ACO environment.

On April 12, 2012, Joslin Diabetes (the world’s largest diabetes research and clinical care organization) and Phytel announced a collaboration on a landmark research initiative to compare the accuracy and predictive value of current assessment methodologies in diabetes care.

Methods of Evaluating Educational Outcomes in Diabetes Care

The study will compare four methods of evaluating educational outcomes in diabetes care:

1. Physician self-reports
2. Competency assessments based on case studies
3. Examination of a sample of patient charts
4. Data drawn from Phytel clients’ electronic registries, which cover all of a practice’s patients with diabetes

“Phytel’s expertise in population health management and its comprehensive database will enable Joslin to make valid comparisons among different methods of assessing performance and patient level outcomes relative to educational and non-educational interventions.”

– Julie Brown, CCMEP, director, Joslin Diabetes Center

Quality Initiatives Focus on Physician-Led Population Health Improvement

This is just one of many Phytel quality initiatives that are focused on physician-led population health improvement.

Other recent 2012 announcements include:

• NCQA Approved Use of Phytel Solutions to Meet Medical Home Criteria. Physician practices can receive automatic credits toward NCQA recognition if they deploy Phytel’s patient outreach and care management services.
• Phytel was announced to be on the advisory committee of the AMGA’s Chronic Care Challenge around Hypertension. The American Medical Group Foundation (AMGF) is launching a national multiyear campaign to reduce the burden of hypertension and related chronic conditions.
• Dr. Richard Hodach, Phytel’s Chief Medical Officer authored a peer-review article within HMFA entitled Automation is Key to Managing a Population’s Health. The article discussed requirements for success with population health management include a high degree of clinical data integration across the healthcare organization’s care enterprise and automated tools for engaging patients in their own care.

Whether our clients are pursuing PCMH, ACO or P4P quality initiatives, our solution and services can leverage existing EMR data to help automate and engage patients for population health management across dozens of conditions and measures – all while demonstrating financial performance! In fact, hundreds of physician groups and healthcare systems that collectively care for more than 20 million patients use Phytel’s patient outreach, care management, patient engagement, transitions of care and analytics solutions in population health management.

And Phytel, because of our focus around quality and health outcomes – is invited to become engaged in more and more projects like Joslin Diabetes.

Read our white paper Improving Compliance to Diabetes and Hypertension Protocols Using Coordinated, Proactive Outreach.

Recently, Physicians Practice published an article, “Top 4 ACO Considerations for Physicians.” It posed this question to readers: “Confused about how ‘accountable care’ will affect your practice? We’re here to help.”

Overall, this was a great article with comprehensive points detailing the challenges that physicians and practice administrators need to consider for an ACO model. However, I had some concerns over the prominence the article gave to using an EHR to mine population data. Specifically in point #2, the author briefly mentioned “Additional Responsibilities,” stating that staff needs to take on extra responsibilities for outreach to manage a population etc.

ACOs Will Benefit from Automation

While it’s true that EHR systems have the data, they are specifically designed to assist physicians to care for individual patients, not for managing a population or large patient panels, as ACOs will require. It is crucial that physicians and administrators understand the drastically different workflows and capabilities needed beyond the raw data, and that without proper automation, these “additional responsibilities” cannot be scaled to effectively impact the population and have the potential to break a practice’s back.

For ACOs to be effective, practices will need to closely track a patient’s care history to identify and meet their care needs. This includes monitoring a patient’s status between episodes of care so the practice can intervene proactively, give patients appropriate support, and engage them in their own care. More and more physician groups are using electronic registries and patient outreach programs to assist them in these efforts. By using the registry data from EHRs, these programs can send automated phone, e-mail or text messages to patients, telling them to make an appointment with their physician. Such tools enable physicians to practice at the top of their license and relieve their care teams from being overwhelmed with the responsibilities care management of large populations entail.

Engaging Patients, Managing Care

In effective ACOs, automation will be key to engaging the patient and managing their care, allowing practices to:

• Use registries to track the health status and care gaps of all patients
• Use proactive outreach to notify patients when they need care
• Manage more patients at different levels of risk
• Automate case management and transitions of care workflows
• Implement educational and operational improvement processes

The transition to ACOs and other emerging models of care is certainly top of mind for physicians right now so the more education and communication we can have on these issues, the quicker we’ll reap the rewards of better population health.

Automation tools for population health management will become more important than ever in 2012 as a growing number of healthcare providers begin to take responsibility for the cost and quality of care. Some organizations will further integrate their information systems and automate their care-coordination processes to prepare for the assumption of financial risk. And more and more providers will focus on the patient-centered medical home (PCMH), which can produce short-term financial and clinical benefits while paving the way for the formation of accountable care organizations (ACOs).

Patient-Centered Medical Home Improves Care Coordination

The PCMH is already generating tremendous enthusiasm among providers and payers. In 2012, it will join the mainstream of healthcare delivery as organizations recognize that it is the best vehicle for attaining the objectives of accountable care.

Without the ability to leverage digitized clinical data, it is impossible to achieve the medical home’s primary goal of improving care coordination in a scalable way. Fortunately, the federal government’s HITECH incentive program is driving the rapidly increasing adoption and meaningful use of EHRs. As structured electronic data becomes the norm, many more providers will be able to tap clinical databases for real-time identification of care gaps, automated outreach to patients who need preventive and chronic care, care coordination, predictive modeling and risk stratification of the population. These tools will help providers build successful medical homes and ACOs.

Automation Technology Supports Patient Engagement

Meanwhile, efforts to promote patients’ engagement in their own care will benefit from the accelerating use of automation technology to replace outmoded, inefficient manual processes. In addition to automated patient outreach methods, online educational tools and health-risk assessments will become commonplace. Mobile health applications will proliferate. Most important, physicians and care teams will have the tools they need to maintain continuous contact with patients between office visits or episodes of care.

Population Health Management and Automation

Finally, care management will benefit from the new automation approaches. Healthcare systems are placing care coordinators within physician practices, and those professionals are beginning to leverage digitized health data to help them manage patient populations. We will see much more of this kind of activity in 2012.

A Value Stream is an end-to-end process that flows horizontally through an organization in order to provide value to a client, patient or customer. Many organizations map processes vertically rather than horizontally focusing on a department over the entity that flows through the entire organization. In a horizontal process design, however, because the entity is what is mapped and not a facility or department, handoffs can be visualized and downstream affects identified.

How Many Value Streams Does Your Organization Have?

Many entities can flow through an organization, but only one entity can flow through a single Value Stream. For instance, a patient would represent the primary entity that flows through a medical practice’s or hospital’s core Value Stream, while a staff member, who also represents an entity flowing through a healthcare organization, flows through an entirely separate Value Stream.

Experience has shown that most organizations have between five and eight Value Streams that either directly or indirectly touch their constituents.

What Makes a Value Stream Map Effective?

For a Value Stream map to be effective, it is critical to determine the beginning and ending points of the end-to-end horizontal process. Identifying the beginning and ending of a Value Stream can easily become an area of great debate.

For example, many may feel that the patient Value Stream begins when a person enters the practice or hospital, whereas others may feel that the Value Stream begins through a healthcare branding campaign. Both are correct, but all must agree on which beginning point to use for the Value Stream. The same goes for the ending point. It is generally best to start the process at the very first point in which the entity is touched and then end at very last point.

Identifying Process Steps

Once the beginning and ending process steps are established, individual process steps must be identified in order of flow. These steps represent a noun and a verb combined to articulate a high level action that is necessary to deliver the entity through the process.

After the high level process steps are determined and aligned into the proper flow, the sub-process steps need to be identified for each high level process step. Again, it is critical that each sub-process step be aligned into its logical flow.  It is recommended that during the mapping exercise, the departmental groups performing each sub-process are named. This allows for a cross-functional visualization for the end-to-end Value Stream.

Defining Core Metrics

After the process is mapped, the core metrics for each Value Stream must be identified and measured. This will facilitate continuous improvement by monitoring and measuring the Value Stream against a patient-stated requirement.

Benefits

Some of the benefits in visualizing the path of an entity as it flows through an organization are:

• Staff members can see how their process directly or indirectly touches a patient.
• The effects upstream processes have on downstream processes become evident.
• When changes are made to an upstream process, it is much easier to model the expected downstream effect.
• When quality and process metrics fail to meet requirements, it is easier to determine the point at which the root cause occurred.
• Hand-offs between processes can be better managed. In many cases, the transition between handoffs is where both defects and delays occur.
• Each process step can be measured in terms of its impact on overall cycle-time.
• It can aid in identifying areas for quick improvement.

Conclusion

Horizontally Value Stream mapping how an entity moves end-to-end though an organization can offer many benefits beyond the traditional vertical way of thinking. This method encourages organizations to take a patient-centered focus in how it manages processes and measures success.

Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients discharged from the hospital returns there within 30 days, and between 50 percent and 75 percent of those readmissions are considered preventable. Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its beneficiaries, and other payers spend roughly the same amount every year for all readmissions of non-Medicare patients.

Causes of Readmissions

The immediate cause of a readmission is usually a rapid deterioration in the patient’s condition, related to the patient’s primary diagnosis and/or comorbidities. But in a broader sense, it can be attributed to systemic failures that often begin in the hospital and continue in the fragmented healthcare settings that patients move through after discharge.

The literature on care transition problems shows there are five main areas that contribute to preventable readmissions:

• Poor preparation for discharge
• Patients’ low health literacy and comprehension
• Failure or inability of patients to see physicians for follow-up after discharge
• Lack of hospital follow-up
• Lack of communication between inpatient and outpatient providers

Readmissions occur, by definition, after a patient has left the hospital. Yet the foundation for post-acute care is laid during the hospital stay—and that preparation is often inadequate.

The Role of Medication Reconciliation

A prime safety issue cited by many experts is missing or inadequate medication reconciliation at the time of discharge. The medications that patients received in the hospital are often discontinued at discharge, while the drugs they were taking before they were admitted may or may not be resumed. Dosages may also change.

The Joint Commission has identified medication reconciliation as a key requirement for ensuring patient safety. The Institute for Healthcare Improvement also cites medication reconciliation as an opportunity to reduce readmissions. This is clearly an area in which improved follow-up and communication between a hospital and a patient’s post-discharge providers could significantly contribute to lower rehospitalization rates.

Improving Patient Health and Safety

By preventing readmissions, healthcare organizations could improve patient health and safety while responding to new government incentives and penalties. A patient-centered, automated approach is the most efficient and cost-effective way to reach out to all discharged patients not just once, but repeatedly over the critical 30- to 60-day period post discharge.  Such a model, judiciously combined with high-touch care management for high-risk patients, is the most efficient and cost-effective way to make sure that all patients who have been discharged are contacted and their healthcare needs are properly addressed.

Until recently, a hospital’s responsibility for care may have ended when a patient was discharged. While health systems have used a variety of techniques to reduce readmissions, they have experienced mixed results. But new government incentives, plus a rising awareness of the need to improve patient safety, are placing an increased emphasis on discharge planning and post-acute care.

New CMS Regulations Begin October 2012

Front and center are the Centers for Medicare and Medicaid’s (CMS’) new regulations on preventable readmissions. Starting Oct. 1, 2012, hospitals with “excessive” readmissions—situations in which that number of patients readmitted to a hospital is significantly higher than expected—will lose a percentage of their Medicare reimbursement across the board. In FY 2013, the decrease can be up to one percent of reimbursement, rising to two percent in 2014 and three percent in 2015.

In the first year of this program, CMS will examine 30-day readmission rates for patients with heart failure, acute myocardial infarction, and pneumonia—three of the leading conditions for which patients are readmitted. Beginning in FY 2015, CMS may also scrutinize chronic obstructive pulmonary disorder and several cardiac and vascular surgical procedures.

Lowering Readmissions through Partnership for Patients

CMS has also launched other programs that might contribute to lower readmission rates. To begin with, the agency plans to spend $500 million—or half of the $1 billion earmarked in the Affordable Care Act for improving patient safety—to help hospitals and their community partners decrease readmissions over a five-year period ending in 2016. Through the government-sponsored Partnership for Patients, CMS will pay these “community-based organizations” a set amount per discharge for managing Medicare beneficiaries at high risk for readmission.

Other Incentives: Payment Bundling and ACOs

Two other CMS initiatives authorized by the health reform law are worth considering: payment bundling and accountable care organizations ACOs). Under CMS’ recently announced plan for its bundling demonstration, providers may choose among four different options. One option includes all care provided from admission to the hospital to 30 or 90 days after discharge. Another would cover only post-acute care for up to 30 days.

In both scenarios, providers would be paid on a fee-for-service basis, adjusted retrospectively for variance from a budgeted amount. While neither option penalizes providers for readmissions, both encourage improvements in the quality of post-acute care, which should reduce the number of readmissions.

Shared-Savings Program for ACOs

Finally, next year CMS will launch its shared-savings program for ACOs, which are groups of hospitals and doctors that are committed to raising the quality and lowering the cost of care. To receive financial rewards from CMS, these organizations will have to save money, which will give them a strong incentive to cut readmissions.

Nevertheless, it will be difficult for healthcare organizations to decrease readmissions significantly in our fragmented, uncoordinated healthcare system. While most of the levers of improvement are known, reengineering inpatient processes and engaging patients and outpatient providers remains challenging.

Leveraging Technology to Auomate the Post-Acute-Care Process

Fortunately, new applications of health information technology now offer inexpensive ways to automate post-acute-care processes. These solutions can raise the effectiveness of care managers, improve the communications between inpatient and outpatient providers, and make it easier for patients and caregivers to absorb and apply the knowledge required for self-management of complex conditions.

A growing number of primary group practices are taking a proactive approach to care management because they know coordinated care will be a linchpin driving impending changes in the care delivery system. Larger organizations especially are building the infrastructure they will need under new delivery and payment systems that are emerging for Medicare, Medicaid and commercial programs.

Medicare’s PGP Demonstration

Let’s look at the Medicare PGP program for example. The experiences of the 10 groups that participated in Medicare’s five-year physician group practice (PGP) demonstration show exciting examples of how these healthcare leaders took on the challenge of care coordination inside their practices and between sites of care to meet their goals.

Incentives for Innovation

The PGP pilot turned out to be a dry run for Medicare’s shared savings program for accountable care organizations (ACOs). Similar to what’s been proposed for the Medicare ACO program, the PGPs were eligible to split savings with Medicare if they met certain quality benchmarks and the savings exceeded 2 percent of expected costs.

In the demonstration project, participants could keep up to 80 percent of the savings they generated, depending on how well they did in meeting 32 quality goals, which is a powerful incentive for finding innovative and effective ways to better manage patient care.

Quality Improvements

According to the Centers for Medicare and Medicaid Services (CMS) report released in July 2011, in the fifth year of the five-year demonstration:

• All 10 groups achieved benchmark performance on at least 30 of the 32 measures.
• 7 groups achieved benchmark performance on all 32 performance measures.
• All 10 groups achieved benchmark performance on the 10 heart failure, 7 coronary artery disease measures and 2 preventive care measures.

Also for Year 5, four of the PGPs earned incentive payments based on the estimated savings in Medicare expenditures for the patient population they serve. The groups received performance payments totaling $29.4 million as their share of the $36.2 million of savings generated for the Medicare Trust Funds in performance Year 5.

Reasons for the Savings

The PGPs attributed their savings to a number of factors:

• Organizational structure
• Investments in care management and care redesign
• More intensive diagnostic coding
• Changes in market conditions

Each PGP that achieved savings used different care management strategies that may spark ideas for other primary care groups moving towards ACO models and similar population health models.

• The Dartmouth-Hitchcock Clinic in Lebanon, NH, focused on evidence-based care initiatives, including better use of care alerts, changing workflow for support staff, and using nurse case managers to work with high-risk patients.
• St. John’s Clinic in Springfield, MO, used a comprehensive patient registry, care alerts at the point of care, a case manager in the emergency department to plan transitions of care, and a care team dedicated to patients with congestive heart failure.

Conclusions

RTI International, the company that analyzed the PGP pilot for the CMS, drew these lessons from the test, many tied to the use of technology-based solutions:

• Medicare patients often have several comorbidities that need to be treated simultaneously. Therefore, group practices must address the need for complex care management that goes beyond traditional disease management for single conditions.
• Complex care management could be enhanced by combining disease-specific patient registries, or by using registries that encompass all patients.
• Planned visits can be facilitated through the use of data systems (e.g., registries and electronic health records) that analyze data and provide physicians and other clinicians with pertinent information about the patient prior to a visit. A visit planner report may, for example, provide a list of overdue tests for a patient that could be performed prior to a visit.
• Key change opportunities include increasing patient engagement, expanding care management, improving care transitions, and expanding the role of nonphysician providers.

The groups that were part of the PDP pilot demonstrated that technology, such as patient registries, plays a major role when adopting a proactive approach to care management.

What’s Next

In future blog posts, we will build on these takeaways, and talk about how the combination of technology and automation can foster even greater strides in population health.