In December, more than 100 healthcare professionals gathered together to discuss leveraging digital data and technology to manage population health cost effectively. A key takeaway was that new care delivery models require new workflows, and new electronic tools are needed to automate those workflows – as seen in this example of managing 8,000 diabetic patients in a multispecialty group.
Imagine you’re the CMO of a multispecialty group with 50 providers, half of them primary care doctors. Your network has 250,000 patients and a business that’s 70% commercial insurance. The group received NCQA recognition in 2011 for its patient-centered medical homes (PCMHs), and it’s considering some risk-based contracts.
A health plan with 100,000 patients wants the group to sign a quality-based contract to manage patients with diabetes. The main goal is to decrease the number of patients who have high A1C values. If the network can do that, it will get a bonus.
The group first needs a high-level overview of the diabetic patients who are insured by this health plan. Based on the prevalence of diabetes in the population, there are about 8,000 patients in that category. Currently, only 38% of them are in full compliance with their care plans. To reach the goal, the group will need to reduce the percentage of diabetic patients with an A1C > 9.0 from the current 28% of the diabetic population to less than 15%.
The group has an application sitting on top of its EHR that can identify the patients with diabetes and attribute them to their primary providers. It also extracts the baseline A1C values for this population. You can also see how individual providers are doing and how they could improve.
Using this data, you can sit down with the providers, explain what the contract is about, and give them data on their performance. Next, you can share your findings with the group’s quality committee, which sets goals, such as see all diabetics twice yearly and decrease their average A1C by one percent within a year.
To meet these goals, the group can use automation tools to:
- Risk stratify the population
- Segment the population by condition, insurance, etc.
- Identify care gaps
- Alert patients who have care gaps that they need to make appointments
- Help care managers identify high-risk patients who they need to focus on
- Enable care managers to initiate a variety of micro-campaigns for all patients with diabetes
- Help providers do pre-visit preparation
- Survey patients to improve post-discharge care and ensure that the patients get their questions answered
- Generate performance reports for physician feedback, showing doctors how they compare with their peers and national benchmarks
Automation tools like these can facilitate most aspects of population health management. In addition, providers that use Phytel solutions can get auto-credit toward NCQA recognition of their PCMHs.
Learn More
Download a whitepaper, The Promise of Population Health Management: New Technologies Are Required to Automate Expanded Physician Workflow.