Improving the Health of a Population Through Collaborative Care

Showcasing Crystal Run Healthcare Improving the Health of a Population Through Collaborative Care Five strategies for success Improving the Health of a Population Through Collaborative Care As healthcare reimbursement shifts from volume to value, organizations are focusing less on episodic care and more on managing population health and wellness, taking an expansive and longer- term view of healthcare to optimize outcomes. Leverage meaningful1 analytics Improving the Health of a Population Through Collaborative Care As practices onboard a myriad of health information technology—electronic health records (EHRs), data warehouses, practice management solutions, and so on—the volume of patient data to which an organization has access grows exponentially. Being able to thoroughly analyze this data allows a practice to fully appreciate the current health of its population, identifying trends, patterns, and outliers that warrant further study. Moreover, engaging in comprehensive analytics enables risk stratification, where an organization segments its population by care needs to better focus resources and deliver targeted care. By drilling down into data this way, organizations can ultimately be more proactive in improving their patient panel’s health with improved outcomes and reduced care costs. These are key elements of the population health initiatives needed for performance-based, accountable care payment models. Improving the Health of a Population Through Collaborative Care Consider the example of Crystal Run® Healthcare, a multi-facility physician practice located in upstate New York with more than 300 providers representing more than 40 medical specialties. The organization is a national leader in the use and advancement of EHRs and other health information technology (HIT) and is designated by the National Committee for Quality Assurance (NCQA) as a level-three patient centered medical home (PCMH) as well as one of the first accredited Accountable Care Organizations (ACOs). When it comes to data analytics, the practice pursues a multifaceted strategy. Improving the Health of a Population Through Collaborative Care To start, Crystal Run analyzes billing data pulled from its EHR and matched to the master patient index, to identify high utilizers—those patients who are seen frequently or have certain diagnoses (such as congestive heart failure and COPD) that, if poorly managed, can lead to hospital admissions and/or have critical test results that need attention, including diabetic patients with elevated A1C levels. Improving the Health of a Population Through Collaborative Care Once these high-risk patients are identified, the organization works to anticipate and respond to their care needs, employing a variety of interventions that range in scope and scale. For instance, if a patient’s condition is less critical, the practice may just reach out to make an appointment or implement a standardized treatment protocol to drive care. For more complex patients, the practice may assign a nurse manager who regularly reviews the patient’s record, assesses risk factors, coordinates care, and ensures compliance and follow-up. By matching escalating interventions with higher- risk patients, the organization not only improves patient care, it also allocates its resources more effectively. A win-win for both patient and practice. Improving the Health of a Population Through Collaborative Care Certain types of visits, such as hospital admissions and discharges, also trigger the practice to take action. The organization runs a daily report showing all the patients who have been admitted to or discharged from partner hospitals. The practice reaches out to these individuals—whether in the hospital or at home—to assist with the transition. A dedicated Crystal Run care manager is embedded in one hospital to smooth care transitions and help prevent unnecessary readmissions. Depending on the patient and the intricacies of his or her condition, the practice may even send a nurse to the patient’s home to reconcile medications, make follow-up appointments, double-check medical equipment, and so on. Improving the Health of a Population Through Collaborative Care Crystal Run also reviews data to track practice usage patterns, looking at from where patients travel when they visit the doctor and what kinds of patients are being seen in certain locations. This allows the organization to more effectively recruit new specialists and onboard additional practice sites. For instance, if one practice is seeing a large number of prenatal patients, then Crystal Run may consider bringing on an additional OB/GYN to ease workload and enhance care delivery. Improving the Health of a Population Through Collaborative Care The practice also leverages data to improve performance. For example, last winter the organization analyzed data to assess how well it responded to a large snow storm, seeking ways to optimize patient care during inclement weather and limit continuity disruptions. Multiple processes including physician snow plans, phone team scripting, and “access Saturdays” were developed as a result of this. For the most part, Crystal Run elects to use billing data in its analysis efforts because of the information’s accessibility and timeliness. While claims data can provide valuable information about care costs, it can be challenging to obtain, and by the time providers receive it, it can be up to six months old. Conversely, billing data helps the practice asses in near real time the complexity of its patient population and who is in need of care. Look to support2 interoperability Improving the Health of a Population Through Collaborative Care As more practices participate in ACOs, shared savings models, and other risk-based payment strategies, the need to seamlessly exchange information with multiple diverse systems is becoming increasingly important. Improving the Health of a Population Through Collaborative Care Moreover, interoperable technology offers many benefits for population health management, enabling providers to: Support the creation of a longitudinal patient Offer a wider view of the population by record, which allows providers to look across a giving an organization a more detailed and patient’s care and appreciate the full picture of comprehensive picture of health needs; and treatments, medications, outcomes, and so on; Streamline referrals by ensuring organizations Yield better care on an individual patient basis can quickly and easily share patient information as providers across the care continuum share between providers. information and work collaboratively to deliver more responsive and less duplicative care; Improving the Health of a Population Through Collaborative Care All 200 physicians at Crystal Run use the NextGen® Ambulatory EHR, enabling smooth, easy data sharing and interoperability within the organization. For example, a primary care physician in the practice who shares the same patient as one of Crystal Run’s specialty physicians can exchange information, electronically discuss care options, and work with the specialist to deliver optimal care because both providers are able to access and interact with the same medical record. Crystal Run also is expanding interoperability with organizations outside the enterprise. For instance, the practice uses a HISP (health information service provider) to securely transport encrypted health information, such as pictures, reports, and continuity of care documents (CCDs), in a standardized format to external healthcare providers. This is especially helpful when communicating with local hospitals and specialists that use different EHRs. Crystal Run also uses secure email for messaging between providers. Improving the Health of a Population Through Collaborative Care Going forward, cutting-edge interoperability tools from NextGen Healthcare and Mirth—including flexible interoperability interfaces embedded in the EHR—will further increase Crystal Run’s ability to share information seamlessly and securely. In the future, patient data from external sources will directly import into a patient’s medical record, improving workflow and efficiency while enabling better care coordination. Offer robust3 care management Although analyzing and sharing data are key to accountable care and a strong population health management program, healthcare organizations cannot forget the human element. In other words, practices must be able to turn information into action—and the key to this effort is targeted care management. Improving the Health of a Population Through Collaborative Care Crystal Run has an especially strong care management program, allocating significant resources to that work. First, they have dedicated care managers in various medical homes who partner with patients to improve their care, sometimes visiting high-risk patients in their homes to perform medication reconciliation, assess treatment compliance, and provide patient education. These care managers also look for potential problems that, if left unchecked, could lead to a hospital admission. They also work to employ therapies that mitigate problems and reduce the need for acute care. Improving the Health of a Population Through Collaborative Care The organization also embeds care managers in local hospitals to smooth discharge transitions—a time fraught with potential risk for certain patients. These care managers visit with Crystal Run patients in the hospital and discuss next steps for care. Before discharge, they send information

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