November 29 2017 | 0 Comments | 101 reads Average Rating: 3

Two Health Care Challenges Walk into a Room And . . .

by Dr. Kevin Keck in Population Health

Consider the following situations:

Scenario 1: Patient Behavior Challenge

The patient would engage in constant incidents of self-harm, banging her head against the wall hundreds of times per day. Tracking and addressing this behavior, however, was a difficult challenge for caregivers.

Scenario 2: Communication Challenge

Recognizing the limitations of sending large continuity of care documents (CCDs) as a means of communication, the healthcare organization needed to find a better way to communicate across the continuum of care.

One of the organization’s leaders described the situation as follows: “How do we better communicate across care transitions?” Making modifications to a health plan, changing coverage, changing prior approvals, changing formularies can only get you so far. But I have to take that meaningful information and get it to a provider where that can be acted upon, or the patients’ orders can be changed.”

The Riddle

If you had one thing – and one thing only – what would you use to solve both of these seemingly disparate challenges?

The Answer

Population health.

While, at first blush, it appears as if these two healthcare challenges are nothing alike, they can both be addressed via population health solutions.

In scenario 1, the patient became part of a population health trial that followed 50 individuals at Services for the UnderServed (SUS), New York City. The trial brought paper-and-pencil population health tasks online for easier input and near-real-time patient tracking. As such, clinicians were able to more adeptly monitor patient behavior and were able to target behaviors they wished to decrease, as well as track the kinds and frequencies of medications taken.

“We were able to do this because we were able to bring the data to each doctor,” says Vivian Attanasio, vice president of behavior services at SUS. “We were also able to reduce patient staffing ratios by reviewing this data. Did the patient need a person with them all the time, or were they able to be grouped?” Ultimately, the population health technology allowed clinicians to pull up information on any patient subset and identify outliers, as well as demonstrate progress to the Department of Health on a monthly basis, she adds.

Indeed, with the population health solution in place, staff determined that the patient suffered from headaches caused by a growth on her brain. After doctors installed a stent to relieve pressure caused by the tumor, the self-harm episodes subsided from 800 per day to fewer than 50 in a week. SUS saved money by being able to shift the patient to less costly care and monitoring, and the patient herself was relieved of great suffering.

In scenario 2, instead of sending large CCDs to various providers, Coordinated Care Health Network (CCHN), Oklahoma, is leveraging a population health solution to get needed information to providers. More specifically, CCHN is turning to messaging to send discrete chunks of information where possible, and making alliances with population health vendors to deliver analytics services throughout the network, according to Brian Yeaman, MD, CEO..

“We’re receiving 2.5 million messages a month, which represent about 500,000 encounters in facilities over five states, and we’re delivering about 350,000 medical record requests a month to providers—the right information at the right place at the right time,” Yeaman says.

As part of that delivery, CCHN ensures that the data is clean and that its network providers receive it in near-real time. “If I’m a care manager, I need to be able to pull a point-of-care analytics report, and it’s a lot easier to wait 30–60 seconds for our report than to generate that myself,” Yeaman says.

To enable providers to do the best they can with the data on hand, developers at the network have created a simple 10-point score to identify the relative risk a patient carries upon discharge from a network hospital. “Those help determine what kind of resources that patient needs right then and there,” Yeaman says. “It is about acting at the time of clinical change, need, or transition with real-time data and allowing organizations to later use the clinical data with claims data on longer-term condition management and their reimbursement.”

For an in-depth discussion of how population health played a role in these healthcare scenarios, check out this article “Population Health: Making a Difference with Data.” In what other situations do you think population health has a play?

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Author
Dr. Kevin Keck
Chief Medical Officer

Dr. Keck is SCIO’s Chief Medical Officer and leads the Clinical Analytics development team. His responsibilities include assessing the leakage and the impact of quality and cost in Provider Analytics.

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