Automated Care Tools for Population Health Management
January/February 2013
Automated Care Tools for Population Health Management
With various forms of value-based reimbursement starting to take hold, healthcare providers have become increasingly interested in new care delivery models centered on population health management (PHM).
The goal of PHM is to keep people as healthy as possible and prevent their chronic illnesses from worsening. By ensuring that each patient receives appropriate preventive and chronic care and encouraging patients to become more engaged in caring for themselves, PHM can improve patients’ overall health and reduce their risk of becoming acutely ill. At the same time, it can decrease overall healthcare costs by mitigating risk factors that can lead to the use of high-cost services in a population.
To help achieve these goals, healthcare must be comprehensive, continuous, proactive, and patient-centered. Providers and care teams must try to ensure that patients receive all recommended preventive and chronic care, whether they seek it or not. Patient outreach and non-visit care are thus integral to the PHM strategy (Care Continuum Alliance, n.d.).
PHM proponents also recognize the importance of personal health behavior and environmental factors in maintaining and improving health. So a PHM strategy requires organizations to engage patients fully in their own healthcare. The only way to do that cost-effectively is by deploying applications that automate much of the following processes: identifying gaps in care, patient outreach, patient education, and care management.
To understand why this is so, consider a typical primary care practice in which each physician sees 30 patients a day. With that patient load, doctors and their staff already have little time to make follow-up calls to these patients or to monitor the status of people who have been hospitalized or referred to specialists. Yet PHM requires that they not only do all of this, but also identify and communicate with patients who have not visited in a long time, engage people in maintaining or improving their health, and help educate those with chronic diseases on how to participate in their own care.
Even if a practice simply seeks to improve the health of patients who are chronically ill or have risk factors for serious conditions, this is a very challenging task. In an average primary care practice with 2,500 patients, for example, U.S. census data suggest there are 207 people with diabetes (CDC, 2011) and 162 people with heart disease (CDC, 2007). Among patients over 20 years of age, nearly 25% smoke, 23% have uncontrolled high LDL cholesterol, and 12% have uncontrolled hypertension (CDC, 2012). And almost 36% of American adults are obese—one of the biggest risk factors for chronic diseases (Ogden et al., 2012).
Most of these people require extensive support to modify their risk factors. “Patient behavior is very difficult to change,” notes Robert Fortini, chief clinical officer of Bon Secours Health System, a large healthcare organization based in Richmond, Virginia. “For instance, you’re unlikely to change the behavior of a severely ill diabetic patient in just four doctor visits a year without a more comprehensive population-based program. Providers and care teams must continue to innovate and engage their patients for the best possible outcomes.”
High-touch approaches are required for the high-risk patients, who constitute 2 to 5% of a typical patient population. However, it is unrealistic for office staff and care managers to maintain personal contact with the thousands of people who have modifiable risk factors in a medium-sized practice. So organizations that choose to implement a PHM strategy are increasingly integrating automation tools to produce the best outcomes at an affordable cost.
Manual vs. Automated Identification and Outreach
To facilitate PHM, some organizations use specialized applications that connect a population-wide electronic registry with automated outbound messaging to patients. The purpose of such a registry is to assemble the latest data on the problems, medications, and lab results of a patient population, including what services have been provided to each patient, where they were provided, and the dates of service. By applying a set of clinical protocols to the registry, a practice can determine which patients are overdue for particular types of preventive and chronic care, such as mammograms or diabetic eye exams. When automation software detects patients who need services, it can automatically send out phone, email, or text messages urging them to make appointments with their providers.
Bon Secours has had very good results using this kind of solution in its primary care practices. Just in Richmond, from August 2011 to July 2012, an outreach program made 305,701 automated calls, successfully contacting 78,549 patients. Of those patients, 35,844 made and kept their appointments. And, because many of these patients had not been in to see their physician in a long time for recommended preventive and chronic care services, this program helps reconnect patients to their providers and increases opportunities for ongoing engagement.
“You can’t do that with human intervention,” Fortini notes. “To do that manually, the cost would have been untenable, and the efficiency and scalability would have been lacking. Innovations such as this have been very effective.”
Northeast Georgia Physicians Group, which has more than 135 providers in 39 locations, has also used this kind of care management platform to engage noncompliant patients. Marlene McIntyre, director of quality and patient safety for the practice, says, “The tool automates what would be a very manual process,” adding that it would be a major challenge for nurses just to identify all the patients who should be contacted by reviewing electronic health records.
The application her group has adopted uses data from the practice management system to populate a registry. Based on the clinical protocols that the practice selected, she says, “The outreach program allows us to easily identify those patients who have care opportunities and immediately reach out to them. If you don’t have a system that does this automatically, many patients fall through the cracks and may become seriously ill. You’re waiting for the patient to remember to come in, which often doesn’t happen.”
How does she know these patients wouldn’t have made appointments on their own? “What we see when we review the reports is that there’s a high volume of appointments made in the two or three days after the outreach occurs, and then drops off significantly. It’s easy to conclude that the scheduling of the appointment was prompted by the call.”
Care Management
PHM also benefits from the automation of care management. First, risk stratification solutions can be used to classify a population by their level of health risk. That will show whether patients are high risk and need the personal assistance of a care manager; have less serious chronic conditions but require online support and other interventions, such as nutrition classes or group visits, to make sure they stay on track with their care plans; or are fairly healthy and simply need to be reminded about preventive care and good health behavior.
Much of the required work can be done through automated communications and online or telephonic consultations between patients and care team members. The automation tools can be used to tailor care management programs to a wide variety of patients who have different conditions and forms of that disease. For example, a patient with diabetes who is obese and has high cholesterol will receive different alerts and educational programs than a patient with diabetes who doesn’t have those risk factors. Similarly, a diabetic patient who has the condition well controlled will be treated differently than one who has uncontrolled diabetes.
McIntyre is especially excited about a new analytic program that allows her to see how particular subpopulations are faring. “My favorite tool in the web-based solution is a scatter plot we can use for diabetic patients,” she says. “I can look at all our diabetics across our 50 primary care providers and see where their A1cs fall. On just one screen, I can see thousands of patients and see who the outliers are.”
The care coordinators in Northeast Georgia Physicians Group are starting to use a care management tool to identify the patients who have care gaps, she says. “They’re able to see which patients are on a provider’s schedule, and, right under that patient’s name, see opportunities for them. They can see the patient is past due for an A1c or hasn’t had a mammogram or hasn’t had a colonoscopy.”
By clicking on a patient’s name, care team members can view all of the key data on the patient, such as their last HbA1c result and their last blood pressure reading. While clinicians could use the group’s EHR to obtain that information, McIntyre observes, the data is not designed for care management and can be harder to access in the EHR, requiring users to click through up to eight screens.
She also praises a color coordination feature in the software that helps care managers quickly spot the patients who are in the worst condition. Based on their care gaps and health status, the application highlights patients who have poorly controlled conditions with red icons, while those who are in less serious shape have green or yellow icons next to their names.
“If I’m a care manager and have a certain amount of time that I can dedicate to care coordination, this tool allows me to see which patients are the highest risk, and need my time the most, so I can focus on them,” McIntyre says.
Both McIntyre and Bon Secours’ Fortini emphasize the need for organizations to embed care managers in physician practices to work closely with high-risk patients. For one thing, Fortini notes, physicians may not have time to review non-medical factors while they’re delivering care during the visit. So at Bon Secours, a patient with complex problems may see a care manager right after a doctor visit or make an appointment with a care manager so that the nurse can do a “deep dive” with the patient and uncover barriers these patients are facing that may impact their care. Care managers can also develop personal connections with patients to effect real behavior change. Fortini adds that automation tools can help reinforce this relationship through ongoing communications between care managers and patients, enabling care managers to have an impact on more patients.
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Population health management requires excellent care coordination, including well-planned handoffs during transitions of care such as hospital discharges. Here, too, automation can play a key role in making sure patients receive appropriate care and adhere to their treatment regimens. Riverside Health System in Newport News, Virginia, for example, uses an automated callout tool to follow up with patients discharged from the emergency departments in three of its four hospitals. When a patient is being released from a (emergency department (ED) to go home, a clinician tells that person to expect a follow-up call from the hospital within 24 hours. In this automated, interactive call, the patient is asked to complete a short survey. They’re asked how they’re feeling and whether they understand their discharge instructions, have picked up their medications, and have contacted their primary care doctors. In addition, the follow-up communication urges patients to fill out their patient satisfaction surveys if received in the mail. When patients indicate that they have further questions about their healthcare, they’re flagged on an “escalation list” and routed back to the ED they visited. A nurse can answer their questions and provide further assistance, if necessary. For example, she might help them get in to see a primary care physician if they need to be seen right away. Or she might arrange for them to get a refill on a particular medication while they’re waiting to see their doctor. Between 8% and 18% of patients ask for additional information from Riverside’s EDs on a week-to-week basis, according to Renee Rountree, vice president of emergency services for the healthcare system. Yet the nurses who are in contact with these patients are not overwhelmed by the additional work, she says. Before Riverside adopted the automated solution, she recalls, she asked ED triage nurses to call patients who left the ED without being seen, parents of pediatric patients, and people discharged to home with fever of unknown origin or abdominal pain. When the nurses got busy, they may not have made these calls, and other patients may not have been contacted at all. There are indications that the automated follow-up calls and the personal attention given to patients on the escalation list are having a positive impact on the patient experience and have improved patient satisfaction with the Riverside hospitals. Focus groups show that the follow-up calls make patients feel more cared about, Rountree notes. In addition, she says, the EDs in two Riverside facilities have seen significant volume growth without adding staff, yet their patient satisfaction scores have not dropped. Rountree attributes that partly to the use of the technology. The success of this tool in Riverside’s EDs, she adds, has prompted the healthcare system leadership to consider using it in Riverside’s inpatient departments as well. |
Online Support Tools
Besides alerts about needed care, there are also online health-risk assessments, education, and health coaching tools that can help people better manage and improve their health. According to a literature survey by the Agency for Healthcare Research and Quality (AHRQ), 80% of the studies of interactive, web-based applications and tailored educational tools show that these interventions had a positive effect on clinical outcomes (Gibbons et al., 2009). But they must be combined with other interventions to motivate people to improve their health, the AHRQ report says.
Research shows that patients feel more confident about managing their health condition when they know more about it. Eighty percent of Internet users already seek answers to their health questions on the web—more than seek health information from doctors, pharmacists, or nurses (Fox, 2011 May; Manhattan Research, 2007). But 71% consult physicians or other health professionals when they have serious health problems (Fox, 2011 February). So multimedia, interactive educational programs prescribed by a doctor can be effective.
The same is true of online health coaching, which usually starts with health risk assessments (Reinke, 2009). But, automated education and health coaching tools must be tailored to the target population. They must not only be condition-specific, but they must also be written in consumer-friendly language so that people with low health literacy can understand them.
Recently, the use of home telemonitoring has been on the upswing. A Geisinger Health Plan study found that home monitoring of patients with congestive heart failure cut hospitalization by 44% (AMC & Geisinger, 2012), and a Veterans Health Administration study of the technology also showed positive results (Darkins et al., 2008). Home and mobile telemonitoring provide other ways for healthcare organizations to monitor the health status of their patient populations.
There has also been growing interest in the use of patient web portals and personal health records to increase patient engagement. The government has placed emphasis on these technologies by requiring providers to give patients copies of their medical records as part of the Meaningful Use Stage 2 criteria (CSC, 2012). In addition, the Blue Button software, which has spread from the Veterans Health Administration to the private sector, makes it easy for consumers to download their medical records (U.S. Sept. of Veterans Affairs, 2012). In a world of accountable care, the automation of these modes of patient engagement will become increasingly important.
Conclusion
Population health management completely changes a provider organization’s business model and its approach to care delivery. The strategy shifts from focusing only on the individual patient and maximizing the volume of visits and services to focusing on the entire patient population and optimizing health and health outcomes. Moreover, the distribution of sickness in the population is always changing. To promote health and to help patients who are likely to become ill in the near future, an organization must be able to scale its patient engagement efforts to address the needs of every person in the population.
Weighing the prevalence of diseases and risk factors against the availability of and investment in care managers, it is apparent that healthcare organizations must use automation tools to identify, monitor, and engage the patients who need help in managing their chronic conditions and those who need support in modifying their health behavior. By deploying the analytic, care management, and patient education applications now available, organizations can expand their outreach and care coordination efforts cost-effectively.
Equally important, these tools enable organizations to restore and maintain contacts with consumers who rarely if ever visit their physicians. By reaching out and involving these patients in their own care, healthcare providers make it more likely that their health conditions will be addressed before they become serious and require hospitalization. Moreover, automation tools can help institutions follow up with patients who have been discharged from hospitals or EDs and can help prevent them from being readmitted (see “Automating Transitions of Care”).
Ultimately, PHM requires practices to have an ongoing, consistent and timely set of competencies to identify, reach, and coach all patients about their health and health needs, inside and outside the physician’s office. Automation enables practices to devote care managers to higher risk patients while providing effective communications and tools to every patient to increase their interest in and ability to engage in their own care. Given the volume of patients whom practices manage, the high level of health risk in every population and the incentives in value-based reimbursement models, automated care tools are becoming a prerequisite for success.
Karen Handmaker is vice president of population health strategies for Phytel. She has a unique combination of private- and public-sector provider, employer and payer market experience established over more than 25 years in healthcare. After many years in managed care strategy and process improvement consulting for provider systems, Handmaker moved into the emerging field of care management for employers and payers seeking to improve the health of their populations to reduce costs and increase productivity. In senior roles at leading national care management vendors and benefits firms, she developed and implemented total population health management programs for Fortune 500TM employers, accruing more than 10 years of experience in this arena. Handmaker earned her BA in American studies at Trinity College, Hartford, Conn., and a master in public policy degree at Harvard University’s Harvard Kennedy School of Government. She may be reached at karen.handmaker@phytel.com.
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