4 Essential Factors for Population Health, Accountable Care

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Many hospitals and health systems across the country are beginning to take steps out of their old comfort zone — caring for patients within their own four walls — to start initiatives to provide accountable care and manage and improve the health of their populations.

Carroll Hospital Center in Westminster, Md., is one of those organizations. About 18 months ago, Carroll Hospital launched a strategic planning process to outline a new hospital-wide initiative to reach into the community and focus on improving the health of its population while reducing costs. Bob Edmondson, chief strategy officer of the 193-bed hospital, is leading the charge into population health management and building the base for Carroll Hospital Center to provide accountable care.Bob Edmondson

Here, Mr. Edmondson discusses four factors he has found to be essential when transitioning a hospital to focus on improving and managing population health.

Health information technology. "The exchange of information is critical," Mr. Edmondson says. To facilitate this at Carroll Hospital Center, the system is working with physicians to make sure their electronic health record systems are being properly used, and the physicians are achieving the various stages of meaningful use.

Beyond basic EHR use, Carroll Hospital Center is also building disease registries so data can be absorbed into a central point. Additionally, Carroll Hospital Center has implemented patient portals, "so patients can get more involved in their healthcare," Mr. Edmondson says. Those three aspects — EHR use, disease registries and patient portals — make up the IT foundation needed to improve population health.

Patient-centered medical homes. Transforming primary care practices into patient-centered medical homes and getting them recognized as such by the National Committee for Quality Assurance is an important building block for population health management and accountable care. "[We're] building a team approach…to managing care for patients with chronic conditions," Mr. Edmondson says. A major part of the PCMH transformation is using care navigators and patient coaches to better serve patients with chronic conditions and other high-utilizing patients.

Chronic disease management. Through data analysis and utilization reports, Carroll Hospital Center can identify patients who fall into the chronic disease population it is focusing on. "We can engage [the patients] through the patient-centered medical homes…and build chronic disease management programs around that set of patients," Mr. Edmondson explains, which will eventually improve patients' health and outcomes while creating cost savings.

Physician leadership. "Physicians have to drive the process or it's not going to work," Mr. Edmondson says. Carroll Hospital Center in particular has an independent medical staff model, so it is using a physician hospital organization to drive physician leadership. "The physicians are leading the PHO, and it's remarkable to see what happens when you actually put physicians in charge and empower them," he says.

The PHO has been around for about two years, and its 200 primary care physicians and specialists have been developing clinical and disease protocols in order to better manage care, according to Mr. Edmondson. "We see the PHO as a procurer and basis for becoming an accountable care organization."

Even though the initiative at Carroll Hospital Center is still in its infancy, its accountable care efforts have seen preliminary quality gains, and Mr. Edmondson is confident the program will continue to produce results. "In the long term, we need to focus more on the general health and wellness of the population not just those with chronic disease," he says. Mr. Edmondson envisions a three to five year timeline for Carroll Hospital Center to expand the program to its general patient population.

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