Why should health systems drive integrated population management programs?
As a result of the changing and uncertain healthcare environment, organizations are facing economic and regulatory pressures forcing them to cut down on costs and spending. With hospitals now being penalized for readmissions, healthcare systems are aiming to better integrate and coordinate care with a focus on population health management.
This white paper explores four populations and current best practices: diabetes, fall prevention for the elderly, employee health and wellness and hepatitis C.
Diabetes
Diabetes management is a concern as the prevalence of the disease continues to rise. This has placed pressure on health systems to provide optimal care according to current guidelines. 25.8 million children and adults have diabetes¹. This accounts for 8.3% of the population.[1]
Geisinger Health System
Geisinger Health System (GHS) has designed a provider-led, team-based system of care to more consistently and reliably meet this challenge. GHS developed an all-or-none bundle of diabetes measures and electronic health record (EHR) tools to improve both process measures and intermediate diabetes outcomes.[2] One of the key elements of redesigning the system was focusing on the EHR to help dictate care. GHS implemented a patient portal, which provides an avenue for patients to communicate with all members of their health care team. Most importantly, this portal requires the patient to be actively engaged in their care.[3]
After implementation of the bundle in 2005, initial results were very poor as only 2.4% of GHS’s diabetic patient population attained the nine metrics of the bundle. These nine metrics encompass quality health indicators. This low level of compliance helped motivate physicians to redesign the system of care from a provider-centric model to a team-based model with delegated and accountable responsibilities. After the first year the percentage of patients achieving all nine metrics rose to 6.5% with statistical improvements in all nine measures.[1]
GHS financially incentivizes health care teams to continuously improve on the bundle’s nine metrics. GHS’s initial goal for each practice was to improve its all-or-none bundle by 1%.[1] Transparency in comparing physician results across the board aids continuous improvement efforts. Monthly aggregated results are shared with all GHS physicians. Wide data distribution encourages positive competition among physicians[4], emphasizing a multidisciplinary approach involving the patient.[1] By redesigning their team-based model of care and integrative EHR system, GHS has shown a sustainable improvement in the care of diabetic population.[3]
Fall Prevention in the Elderly Population
Falls are the leading cause of fatal and non-fatal injuries in older adults. One out of three adults’ aged 65 or older fall every year. Falls result in more than 2.4 million injuries treated in emergency departments (ED) annually and costs are expected to reach $61.6 billion by 2020.[5]
Prevention programs are being used by health systems to decrease fall injuries and deaths and reduce the rate of admissions to EDs. There is poor acceptance and minimal credibility of these programs due to the lack of continuity of care once the patient leaves the health system.
In order to develop an effective community-based fall prevention program, there needs to be a focus on medication management, exercise, and home modification.[6]
Currently, fall prevention programs are classified as either single intervention programs or multi-faceted. Single intervention programs are focused on education while multi-faceted programs use clinical and customized intervention strategies with follow up. Research shows that multifaceted fall prevention programs are more effective.[7]
Single Intervention Fall Prevention Program
George Washington University Hospital (GWUH) utilizes a fall prevention program that is focused on patient and community education. A trauma injury and prevention coordinator targets the areas in the community from which patients are admitted to the hospital due to falls and provide education and resources in these areas. These include senior centers, assisted living facilities and nursing homes. GWUH partners with the DC Falls Free Prevention Coalition to increase awareness and collaborate on different community-wide environmental initiatives such as sidewalk safety and home modification grants.[8]
Multi-faceted Fall Prevention Program
Stanford Hospital & Clinics developed Farewell to Falls, a free, multi-faceted program. Once enrolled, seniors receive three home visits by an occupational therapist to assess their health, strength and balance, and home safety. They require seniors to commit to an exercise regimen and provide information on prevention, risks, safety practices and community resources. Participants receive follow up calls throughout the year from senior volunteers to provide support and ensure participation. Farewell to Falls allows providers and patients to build a trusting relationship and embrace a new lifestyle.[9]
Employee Health & Wellness
Employers across the country are aiming to cut costs and control health care spending. Traditional supply-side cost management strategies have had diminishing impacts. The variability of health care quality and the poor correlation with prices has made it more difficult for employers to effectively manage health care costs.[10]
A 2012 survey conducted by the Kaiser Family Foundation found that most employers offering health benefits provide some type of wellness program, with 94% of large firms (200 or more workers) and 63% of smaller firms (3-199 workers) offering a wellness benefit.[11]
When asked why wellness programs are offered, 37% of employers reported that wellness programs are a part of their health plan, while 35% said their goal is to improve the health of employees while reducing absenteeism.[12] Wellness program offerings include: weight loss and smoking cessation programs, nutrition counselors, on-site exercise facilities, stress management tools, among others.
A study funded by the Health Enhancement Research Organization showed that depressed and highly stressed employees cost employers significantly more in health care costs compared with those without these psychosocial risk factors.[13]
The Cleveland Clinic & GSK
The Cleveland Clinic and Glaxo Smith Kline (GSK) are moving away from traditional methods of health care cost reduction. Both organizations are focusing on mental health and stress management to improve productivity and overall health and wellness of their workforce. Integrating health and wellness programs into the company’s strategic vision and culture requires leadership to closely track the program’s goals, milestones and progress.[14] In order to further reduce costs and better manage health and wellness offerings, health systems such as the Cleveland Clinic, Adventist Health Care, and Norton Health Care are moving towards discontinuing the use of vendors and aim to expand the use of their existing assets to support internal programs.[15],[16]
Hepatitis C
Hepatitis C is the most common chronic blood borne pathogen in the United States.[17] The U.S. Preventive Services Task Force has recommended that individuals at high risk and those born between 1945 and 1965 be screened for the disease.[17] Over the years, treatments for those diagnosed with hepatitis C have simplified. This has placed a renewed focus on hepatitis C as more individuals can be cured through less complex and more tolerable treatments. While New York is the only state the mandates the offering of hepatitis C screening to patients born between 1945 and 1965, organizations in other states are rapidly expanding their screening and treatment programs. Barriers at different levels are preventing infected individuals from getting the care that they need. These levels include a patient level, provider level, and structural level.[18]
Total Health Care & Johns Hopkins Infectious Disease Center for Viral Hepatitis
Federally Qualified Health Centers (FQHCs) and the Johns Hopkins Infectious Disease Center for Viral Hepatitis are looking to expand hepatitis C care in the Baltimore area. At Total Health Care, a FQHC, every patient is screened for hepatitis C. If a patient tests positive and they are willing to comply with treatment, they are referred to a specialist provider who will communicate with Total Health Care through progress notes as treatment progresses. Total Health Care providers will coordinate with the specialists and order labs at routine visits if appropriate. Total Health Care is looking to expand the hepatitis C care that they are able to provide onsite by incorporating hepatitis C specialists to the care team. A key challenge with this expansion will be funding and resources.[19]
The Johns Hopkins Infectious Disease Center for Viral Hepatitis currently provides specialty care to those diagnosed with hepatitis C. In order to better meet the needs of the patient population, the center is looking to engage local FQHCs and other health care providers in hepatitis C screening and treatment. In late 2014 through 2015, the aim is to engage and train primary care physicians, nurse practitioners and physician assistants how to administer treatments.[20] Other outreach programs across the country are focusing on community integration and providing free screening for individuals at convenient locations. Some are looking to provide hepatitis C treatment to rural and underserved areas by utilizing telehealth and co-case management between primary care physicians and specialists. Hepatitis C treatment is a lengthy process, which requires patients to be psychosocially ready to complete the treatments’ duration. Clinical interviews to assess psychosocial functioning have proven to be beneficial.[21],[22],[23]
Conclusion
The challenges below are consistent across all four population management programs previously mentioned.
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In order for population health management programs to succeed, multiple factors must be in place. Successful population health management programs should include the following five criteria.
Linkage to the community: By linking services and efforts to the community there will be increased access to services. Additional efforts with support groups, group classes, and integrating text messaging and phone apps will strengthen the link to the community and targeted population.
Strong leadership, culture & multidisciplinary approach: Having a strong leadership presence and culture while utilizing a multidisciplinary team will allow for individuals to receive individualized care that meets their specific needs. A strong culture will aid in creating service line awareness which will create more in house referrals. Strong accountability at all levels of leadership will cultivate a rich culture with a unified goal.
Data collection: The effective use of an EHR system will allow for patients to be tracked and monitored over time and will also be able to flag patients that are appropriate for specific program offerings. An EHR system will allow for interoperability across departments and complimentary programs to more accurately aggregate and compare patient data. An additional benefit of a well-integrated EHR system will be the ability to incorporate a patient portal that allows patients to view test results, among other information, giving them the ownership of their data and the ability to monitor their status independently. Data analysis from EHRs will allow leadership and providers to make better evidence-based strategic decisions.
Accountability: Creating patient accountability ensures medication compliance, consistent follow up visits, and increased knowledge about their condition. By linking the effort to the community and providing patients access to their information through a patient portal and supplementary applications, steps are being taken to foster accountability.
Communication: Placing an increased focus on communication will allow for all stakeholders to remain engaged and current on new developments. The patient portal will facilitate open communication between the patients and their care team. Communication about the program, its efforts, and end goals to the community will help create the linkage and ensure all eligible individuals are aware of the program. Striking a balance between too much and too little communication is key to keep individuals at each level engaged but not overwhelmed by information.
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