Case Study
CASE 1: POPULATION HEALTH MANAGEMENT IN ACTION
Although the integration of patient-centered medical homes and account able care organizations into the health system is still emerging— as are best practices and key learnings from these early efforts— there have been myriad examples demonstrating encouraging returns and improvement in quality of care. The Patient-Centered Primary Care Collaborative recently profiled several organizations that have adopted patient health management (PHM) tools and strategies to address the preventive and chronic care needs of their patient populations.
A pioneer in implementing medical home and accountable care initiatives, Bon
Secours has dedicated itself to executing a sustainable care delivery model that is in
alignment with health care reform across its providers and locations. Bon Secours’s
transformation into an organization that embraces PHM is the result of a systematic
strategy to reengineer primary care practices, integrate new technologies into care
team workflows, and engage patients in their care. Bon Secours took a leap of faith
in implementing these changes, acting on the belief that payers would come to them
if they built a viable model. And payers did. The organization was selected as an
early participant in the Medicare Shared Savings Program. It has also signed value based contracts with two commercial payers— CIGNA and Anthem— and is in
negotiations with several more. These contracts provide a financial mechanism to
expand and scale the medical home initiative and support ACO models. This case
study examines in more detail Bon Secours’s approach to position itself to achieve
quality outcomes and financial success in the changing health care environment.
Bon Secours’s Care Team Model
The foundation of Bon Secours’s strategy for value-based care is its medical home
initiative— the Advanced Medical Home Project. The project began as a pilot five
years ago. Since that time, eleven practices have earned NCQA recognition as
patient-centered medical homes. One of the most significant objectives of the
Advanced Medical Home Project is to improve capacity— making it possible for care
teams to double the size of their patient panel without overburdening themselves or
sacrificing quality of care. At the heart of this medical home strategy is the effort
to reengineer practices by creating high-performance physician-led care teams,
which requires changes in workflow, new care coordination activities, and designed
delegation of clinical responsibilities across the care team. To facilitate this process,
Bon Secours has invested significantly in embedding care managers into the primary
care team. These nurse navigators are registered nurses (RNs) who are either
board-certified case managers or actively working toward certification.
Each nurse navigator is assigned a panel of approximately 150 high-risk patients. He
or she cultivates a personal relationship with these patients, usually through
repeated phone contacts. Although most outreach is tele phonic, navigators have the
skill to assess which patients require face-to-face intervention. And because they are
embedded in the practice, they can spend time with these patients doing
assessments, care planning, and education.
Bon Secours’s eHealth Strategies
An important aspect of Bon Secours’s strategy is implementing health information technology that empowers the care team to efficiently manage the health of
their populations. They consider this technology— standardized across the medical
group— as the key to enable them to scale their system for value-based care. As a
first step, Bon Secours implemented an EHR and all its modules in every practice
within the system. This gave them a strong foundation for documenting care and
accessing health records across the enterprise.
Risk stratification.
They were able to build a registry that could identify high-risk and high-utilization
patients based on data such as number of medications or frequent visits to the
emergency department. However, the organization recognized the need for a more
robust, scalable registry that would drive efficient population health workflows in their
practices and enable analytics and predictive modeling across multiple clinical
conditions. Integrating their EHR with a PHM platform, Bon Secours is able to
aggregate all source data into a population-wide registry that enables the organization to implement multiple quality-improvement programs simultaneously. The
registry stratifies the population by risk— providing a total population view while
enabling each care team to drill down to the data they need about cohorts and
individual patients. The system enables care teams within the practice to monitor
their patients’ health status and take action by delivering timely and appropriate care
interventions. Because the system automates these interventions, care teams are
able to communicate with many patients at once. Automated outreach.
A significant priority for Bon Secours has been preventing thirty-day readmissions.
The medical group uses an automated outreach system to identify discharged
patients, link them to a primary care provider (PCP), and pinpoint those who are at
high risk for readmission. Flagged patients are then called within twenty-four to
seventy-two hours to reinforce discharge instructions, make sure their medications
are reconciled, and set up an appointment with the primary care team within five to
ten days of discharge. Bon Secours will soon implement a readmissions solution to
automate the process of calling discharged patients, asking them to complete a short
assessment, and escalating cases as needed based on their feedback.
Personal health records.
Another strategy for patient engagement is activating patients on an electronic
personal health record (PHR), which allows patients to view clinical results and
communicate conveniently with their caregivers via e-mail. Bon Secours works to
gain physician consensus on policies that drive the use of PHR: physicians agreed to
allow automatic release of normal results to the PHR, but abnormal results are held
for 24 hours to enable the care team to contact the patient. The organization is
relying on physicians and staff members to get patients active on the PHR to help
them sign up on the spot in the exam room.
Challenges and Lessons Learned
Gaining physician buy-in for reengineering practice workflow.
The concept of the care team can be difficult for some physicians because they see
them selves as the clinician and the rest of the team as support staff members. To
help physicians embrace the care team and delegate patient-care tasks, Bon
Secours placed tremendous emphasis on physician education. The organization also
allows physicians to adjust some of the standardized care team protocols to meet
the needs of their practice, which fosters ownership of the process and assures
physicians that they remain in control.
Paying for the transition to value-based care.
As mentioned previously, Bon Secours implemented its medical home model with
the hope that payers would come to them if they built a viable program. CIGNA
currently gives the organization a per-member per-month (PMPM) adjustment for
care coordination. Anthem, the group’s biggest payer, pays a care coordination fee
and will change to PMPM in the coming year. Several more commercial payers are
lined up to sign contracts with the group. However, this payer involvement is a
relatively new development. For the first few years of the project, Bon Secours
shouldered the expense. The organization is now poised to reap the rewards of its
investment. Bon Secours is also demonstrating significant progress managing its
CIGNA population. In the first six months of their value-based contract, they have
achieved a 27 percent reduction in readmissions and are $1.8 million below their
projected spend. They have hit many of their care quality metrics and need to
improve their gap-in-care metrics only slightly to achieve the index necessary to
qualify for gain sharing with CIGNA— a development that will bring a projected
annual savings of $4 million. Bon Secours’s mantra for the future is “health care
without walls.” The organization is aggressively pursuing remote, noninvasive
monitoring forhighly acute case management. Their vision is to bring care outside
the four walls of the hospital into the patient’s home using technology. They are
operationalizing a geriatric medical home that will enable patients to age in place
with home visits for preventive and acute management. They are also expanding
their implementation of the PHM platform to include performance measurement at
the group, site, and provider levels; feedback to providers on variance in care; and
quality reporting. This added functionality for analytics and insight on the clinical and
administrative levels will help the organization ensure that it is meeting the triple aim
(to improve the patient experience of care, including quality and satisfaction; to
improve the health of populations; and to reduce the per capita cost of health care).
Innovation Impact
• Thirty-day readmission rate for medical home patients was < 2 percent for two years. • Patient engagement scores were in the 97th percentile. • Patient outreach efforts generated approximately forty thousand unique patient visits for preventive, follow-up, or acute care, leading to $7 million increased revenue. Answer discussion questions: 1.What do you think are the important take-home messages in this case? 2.What is your assessment of the approach Bon Secours has taken in embracing its commitment to population health management by investigating in different IT capabilities? How useful are capabilities such as risk stratification, automated outreach, and PHRs in improving quality while managing costs? Are there other tools that could have been useful? If so, what are they? How might they be used?