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 about the patient to one of the office-based care managers so he or she can coordinate post-discharge communication and treatment. These hospital-based care managers also send alerts to the primary care physician and relevant specialists as the patient is being discharged.

All of this personnel investment and data exchange ensures appropriate post-discharge care and that all relevant information from the hospital is reconciled against the patient’s primary care record, preventing medication errors and complications that could result in readmission. Improving the Health of a Population Through Collaborative Care

To further support care management, Crystal Run also has a strong home monitoring program in which nurses watch changes in a high-risk patient’s condition through Bluetooth-enabled scales, pulse oximeters, blood pressure cuffs, and other equipment sent home with the patient. If the patient starts trending in a direction outside the normal range, the organization is automatically notifiedand can check in with the patient over the phone, make adjustments to medications, visit the home, or engage in some other intervention. Improving the Health of a Population Through Collaborative Care

Although Crystal Run currently has a high-functioning care management program, the organization is not resting on its laurels. The practice is working with NextGen Healthcare and Mirth to develop and implement an advanced care management tool, designed to speed informed, personalized care to patients who need it. Basically, it will function like an electronic medical record for care managers... seamlessly integrating with existing NextGen Healthcare software to facilitate more collaborative and cross-continuum care. Incorporate population health management4 into workflow Improving the Health of a Population Through Collaborative Care

Managing the health of a population represents a departure from how provider healthcare organizations have traditionally provided patient care—as opposed to zeroing in on a single patient’s needs at a particular point in time. To get physicians and other providers on board with this new way of thinking, organizations have to make population health management activities fit into existing workflow. Improving the Health of a Population Through Collaborative Care

As with other aspects of healthcare delivery, if population health processes are too confusing or cumbersome, or take a physician off track from providing direct clinical care, they won’t be successful. Embedding population health management into workflow is about efficiently getting providers the information they need in a format they can use.

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Crystal Run uses easy-to-read dashboards and reports to show providers information about the health of their patient population, allowing physicians to quickly see areas of opportunity and gauge progress toward improvement. In addition, the practice hosts medical home meetings in which health data is shared with the entire care team so everyone is on the same page about how to effectively manage population health. Improving the Health of a Population Through Collaborative Care

Incorporating population health management tools into the EHR is another way to embed these activities into workflow, helping providers respond immediately to high-risk patients when they talk to them on the phone, exchange email, or see them in the office. For example, Crystal Run is working with NextGen Healthcare to bring “risk scoring” into their EHR so a clinician can look at a patient record and see at a glance what the level of risk is for readmissions, negative health outcomes, and so on. The provider can then take action to prevent possible issues and improve patient care.

Although Crystal Run has already started manually assigning risk scores to patients, it is a cumbersome process. Automating the effort will bring critical information to the point of care faster, allowing providers to seamlessly integrate the work into daily operations. Engage5 patients Improving the Health of a Population Through Collaborative Care

All the data, technology, and analytics in the world won’t improve the health of a population if the patients themselves are not willing to engage in their health. For example, you can tell someone she needs an annual mammogram and make the appointment for her, but if the individual does not see the value in the mammogram or doesn’t prioritize getting it done, it may not happen. For this reason, finding concrete ways to engage patients in their health is an essential—and often elusive—part of population health management. Improving the Health of a Population Through Collaborative Care

Crystal Run employs several different engagement strategies. First, the organization streamlines patient access, making it easy for individuals to make appointments, ask questions, and fill prescriptions. By offering tools such as online appointment scheduling and a patient portal, the practice ensures patients can better communicate with their providers and coordinate health appointments, schedule lab work, and review test results.

Nearly 10 percent of their active patients currently utilize the patient portal. Improving the Health of a Population Through Collaborative Care

To further drive engagement, Crystal Run is looking to onboard a mobile app that will foster more bi-directional communication, allowing patients to perform routine care management tasks using their phones. This technology is just starting to take hold, and the practice hopes it will ultimately boost patient involvement in care. Improving the Health of a Population Through Collaborative Care

In addition to facilitating greater access, Crystal Run has instituted several outreach programs to capture the attention of patients interested in improving their health. For example, the practice offers meetings and educational sessions in the evenings and on weekends for people who want to learn more about a specific topic, such as asthma care or diabetes prevention. Improving the Health of a Population Through Collaborative Care

One particularly creative initiative, called the “Walk with a Doc” program, educates patients while promoting heart health and exercise. Participants meet at a local park to listen to a presentation by one of Crystal Run’s doctors and then they go on a walk together. This gives patients an opportunity to build comradery with the physician, seeking information while engaging in good fitness. Improving the Health of a Population Through Collaborative Care

Looking ahead, Crystal Run is developing a patient activation project which will involve targeted marketing to empower patients to make changes in their lifestyle and embrace the fundamentals of healthy living. They also are considering offering incentive programs, such as ones that involve a personal fitness tracker, to encourage regular exercise, healthy eating, and sufficient sleep.

changeshealthy eating lifestyle sufficient sleep regular exercise fitness tracker fitnesshealthy living empower fundamentals When data, technology, and people come together, population health improves As you have read, there are many ways healthcare organizations can work to enhance their population health management initiatives. Fundamentally it comes down to this: the more an organization is able to leverage data and technology to segment populations, deliver targeted interventions, engage patients, and proactively mitigate risk, the better it will be at managing the health of its patient populations. Improving the Health of a Population Through Collaborative Care

To do this effectively, organizations must commit to collaboration and be ready and willing to work with other providers, vendors, payers, and patients to improve care, elevating health and wellness across the country.

The results are telling. Crystal Run Healthcare has been able to decrease avoidable admissions by 15 percent and decrease 30-day readmission rates by 11 percent, all while improving quality scores across the board.

For more information about Crystal Run Healthcare, visit www.crystalrunhealthcare.com. For more information about NextGen Healthcare’s solutions, call 855-510-6398 or visit www.nextgen.com.

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