Texas Children’s Hospital uses a population health approach, fueled by data analytics, to manage care for 4,500 young patients with diabetes.
The goal is to reduce hospital admissions and lengths of stay as well as to increase the number of patients whose diabetes is controlled, which the American Diabetes Association defines as a hemoglobin A1c level of less than 7.5.
In 2014, the Houston-based hospital launched improvements in hospital care for children and teenagers newly diagnosed with either type 1 or type 2 diabetes. Those improvements included:
- Dedicated beds on an inpatient unit for children with diabetes and staffed with nurses trained in diabetes management and education.
- Patients treated entirely in dedicated diabetes beds rather than partially in the ICU.
- Standardized electronic best practice alerts and order sets.
- Care plans created with input from family members.
As a result of these changes, the average length of stay dropped from 2.8 days in 2013 to two days in 2016.
Children’s Hospital expanded the project in 2015 to its two suburban pediatric hospitals, including one slated to open in 2017; numerous outpatient settings; and community outreach efforts, such as with community-based providers and girl scout troops.
“Once we achieved those early aims, we realized that we had the momentum and bandwidth to start looking at a much larger population of patients,” explains Rona Sonabend, MD, assistant professor of pediatrics and endocrinology at Baylor College of Medicine and medical director of clinical systems integration process improvement and co-leader of the diabetes care process team at Texas Children’s Hospital.
With the expanded focus, hospitalizations for diabetes ketoacidosis, or DKA, a life-threatening complication of diabetes characterized by high levels of ketones in the blood, declined. For example, the percentage of patients with multiple admissions for DKA in one year dropped from 24.2 percent in fiscal year 2015, which ended Sept. 30, 2015, to 12.4 percent in fiscal year 2016.
The hospital also logged improvements in A1c control for its youngest patients, or those from birth to age 5.
Texas Children’s Hospital is not alone. As part of their population health initiatives, health systems are segmenting patients into groups and defining care processes tailored to each group. They also are also coordinating care across healthcare settings, teaching patients how to manage their health effectively, and helping chronically ill patients avoid high-cost ER visits and hospital stays.
The patient groups usually are formed based on chronic diseases, such as diabetes or hypertension; common preventive services, such as cancer screenings; high-cost patients or patients at risk of becoming high cost.
To segment patients into groups, health systems aggregate and then analyze data from EHRs, financial systems and other sources. After developing action strategies based on their analysis, they also use analytics to track improvements in costs and clinical outcomes by provider, clinic and institution.
That’s the path Borgess Health has followed. For example, the three-hospital system based in Kalamazoo, Mich., decreased the number of adult patients with uncontrolled diabetes from 29 percent in March of 2015 to 15 percent in June of 2016.
To define this population, Borgess included adult patients with a hemoglobin A1c greater than nine as well as adult patients with diabetes whose A1c had not been checked in more than a year. “From a population health perspective, anybody who was not screened in the last year is considered uncontrolled because you don’t know what they are,” explains Cindy Gaines, vice president and chief operations officer at Borgess Health.
After analyzing the data in that group, “what we found is that the actual percentage of patients who had a hemoglobin A1c of greater than nine was only about 10 percent,” Gaines says, demonstrating that providers’ methods for teaching patients about diet and disease management were effective. “But we had this whole group of patients who hadn’t been in in more than a year.”
Borgess uses a cloud-based population health platform from Wellcentive, which was purchased in 2016 by Royal Philips, to define, analyze and measure outcomes for distinct populations of patients.
Armed with information about patients with uncontrolled diabetes, clinicians and administrators developed an action plan focused getting patients who hadn’t had their A1c level checked in more than a year back into the healthcare system.
“If we hadn’t had the Wellcentive data analytics tool to help us to parse out those patients, we would have focused on education and diet, and that is not what they needed. They needed to be checked; that’s a whole different action plan,” Gaines says.
Aiding preventive care
Borgess has applied the same approach to preventive care. One example is mammography. After analyzing aggregated patient data, Borgess executives realized that compliance with standardized screening recommendations varied by age group. “The older you became in our data, the more likely you were to get a mammogram,” Gaines says. Women between the ages of 40 and 50 had the lowest screening rates for mammography.
The action plan for these women focused on making it easy for them to get a mammogram. For example, Borgess lets patients schedule their appointment on the health system’s website and doesn’t require patients to obtain a doctor’s order for a routine screening mammogram.
These and other tactics paid off: The mammography screening rate for women between the ages of 40 and 50 rose from 68.25 percent in June 2015 to 74.71 percent in June 2016.
In the current fiscal year, which began on July 1, 2016, Borgess is working on colorectal cancer screening. “Our biggest challenge has been the cleanup of the data,” Gaines says. It was difficult for Borgess analysts to track colonoscopies if physicians performed them at non-Borgess facilities. While the health system’s staff routinely scanned paper reports about these procedures into patients’ electronic health records, the information was difficult to find, Gaines says.
To solve this problem, the health system’s staff now adds a label, which includes a unique identifier for colonoscopy, to each report before scanning it into the EHR. The unique identifier creates a discrete data element in the EHR that Borgess then pushes into the Wellcentive population database.
IT supports shift
Information technology is at the core of population health management at Texas Children’s Hospital, too.
Children’s Hospital exported data about numerous diseases from its EHR and other sources into an enterprise data warehouse, which it built using technology from Health Catalyst. From there, it developed patient cohorts, such as children and teenagers with diabetes who receive care at Children’s facilities.
Health Catalyst’s enterprise data warehouse architecture is based on what the company calls a “late binding” approach in which data from various sources is ingested into the EDW but not immediately formatted with standard vocabularies and rules. The formatting happens later to meet the needs a of a specific project.
Using this approach to data analytics, Texas Children’s Hospital developed a multi-faceted action plan to improve diabetes care, going beyond an initial hospital stay. Children’s staff diagnoses about 350 new cases of diabetes per year, and most of those children and teenagers begin treatment for the disease during their hospital stay.
For example, the hospital added behavioral health components to its outpatient care plans. Recognizing the role that behavioral health issues, such as depression, and socioeconomic factors, such as income, play in the ability of patients and families to manage diabetes, the hospital hired social workers and a psychologist with specialized training in diabetes to work with patients and their families.
Each patient meets with a social worker at least once a year; the number of additional visits a child or teenager has with a social worker is based on their current behavioral health needs or their risk of developing behavioral health issues.
In addition, children and teenagers who are at high risk of developing DKA are assigned to a social worker who helps these patients and their families coordinate healthcare services and tap into social services, transportation, and medication assistance programs.
Texas Children’s Hospital also has standardized medical care delivered in the outpatient setting to all diabetes patients, adhering to guidelines developed by the American Diabetes Association, and including such metrics as the frequency of doctor’s office visits, routine blood tests, and eye exams.
The hospital also has expanded beyond its doors, targeting the larger community as well. For example, its staff developed webinars for pediatric nurses and physicians in the community, and it also supports girl scout troops comprised of girls with diabetes and their siblings.
“There are many, many balls being juggled at the same time with the goal of improving outcomes for these patients,” Sonabend explains. “What we are really targeting is how do we improve the health of the entire population—not just when we see them as an inpatient and not just when they come in for their office visits? How do enhance the entire population’s health?”
Solving complex cases
In addition to chronic diseases and preventive care, health systems also stratify patients who are medically complex and high cost as well as those at risk of becoming high cost.
Partners HealthCare has been working to define and coordinate care for these chronically ill patients since 2006.
Partner’s Integrated Care Management Program, or iCMP, evolved out of a Medicare demonstration project at Massachusetts General Hospital in which care managers helped the sickest 15 percent of Medicare beneficiaries navigate the healthcare system.
During the program’s first three years, Massachusetts General saved $2.65 in healthcare costs for every $1 it spent on the program.
Since then, Partners has expanded the iCMP to its other facilities and all public and private insurance plans. Partners now targets patients at risk of becoming very high cost. “We are looking at those who are projected to hit the top 1 percent of expenses,” says Sreekanth Chaguturu, MD, vice president of population health management at Partners HealthCare. The goal is to intervene with care management services before patients’ health declines to the point where it is difficult to control costs.
The program revolves around the work of about 100 nurse care managers, who develop customized care plans in collaboration with primary care providers and patients. The care plans “are very specific to that patient’s needs,” covering biomedical, social and mental health issues, Chaguturu says.
Care managers then execute those plans for up to a year through offices visits, home visits and phone calls. They address issues that impede patients’ ability to comply with their care plans, and they also coordinate services, such as transportation, diagnostic tests and care provided by medical specialists.
Northwestern Medicine Physician Partners, a clinically integrated network that operates primarily in Chicago’s western suburbs, launched its care coordination program for chronically ill patients in April 2016. The patients in its program have an average of four chronic conditions, including behavioral health diagnoses, as well as social issues that make it harder for them to follow their care plans, such as the lack of a caregiver in the home.
The program currently employs 12 care managers who coordinate care in conjunction with about 120 primary care physicians.
Patients for the program are drawn from among 50,000 enrollees in numerous value-based public programs and commercial insurance contracts. “The care management nurses will be involved with the patients, either two or three times a week or monthly. We continue to contact those patients until their care plan has reached a level of stability, and they have improved in their self-care,” says Gary Wainer, DO, medical director of Northwestern Medicine Physician Partners.
As part of its goal to improve care for chronically ill patients, Wainer says Northwestern is evaluating new options to address behavioral health needs, such as using telemedicine technology for virtual counseling sessions. “We are still very much in the study phase,” Wainer says.
While most of the work in population health management nationally has occurred at the primary care level through care coordination and other programs, Partners also has expanded its focus to include specialists. To do this, Partners has brought groups of physicians within a specialty together in committees to develop clinical quality measures.
Partners exports data on specialty services from financial systems, medical records and other sources into an electronic data warehouse, which the health system built using the late binding data architecture from Health Catalyst. Specialists use analytic tools from SAS to analyze the data. Their work “is much more of a classic explorative use of a warehouse for things we have not fully defined,” Chaguturu says.
The first specialty to go through this process was nephrology. About 12 specialists developed process and outcome metrics for chronic kidney disease, such as blood tests to monitor kidney function and tracking of patients’ smoking habits. Partners has launched similar teams for other specialties, such as neurology and orthopedics.
Explains Chaguturu, “Each one of these requires a fair amount of work to bring the clinicians together, to get the data, and identify those measures. You can think of the conceptual measures, but then how do you actually find the numerators and denominators in your warehouse that actually translate into meaningful measures?”
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