Delaware | 50 states of population health


JOHN FINK, MD. Family medicine physician with Bayhealth (Dover, Del.)

On the top challenge

"What we're recognizing is the care of our patients is really going outside the four walls of our institutions. We're looking at care provided across the spectrum from home care to post-acute facilities [to] community practices [to] surgery centers. What used to be done mostly in hospitals a while back is now spread out across a number of different healthcare facilities — and even patients' homes — that, as a healthcare organization, we have either limited or no direct input on. From [the perspective of] managing population health, what we're having to do is make sure we're aligning ourselves correctly with the right partners and also creating partnerships with community providers, with other healthcare organizations in the state, to make sure we can ensure the best care is provided across the spectrum."

On the hospital's response

"It starts with things like our ACO that we're in now with several other healthcare organizations in the state. That particularly affects our Medicare population obviously, but we also have strategic partnerships with several other large organizations throughout Delaware. Organizations themselves recognized they couldn't do this alone, so they started sharing best practices and looking into models for how to really provide the best care for patients throughout Delaware.

We have [also] been working for a number of years with a clinically integrated network that we call the Bayhealth Physician Alliance, which is a partnership between Bayhealth and our community practices — both employed physicians and community physicians. Additionally, we have a business intelligence software tool that helps us collect patient data and aggregate it across 30 or so EHRs throughout the whole clinically integrated network to provide a snapshot of the type of care and the level of care that we're providing throughout our community.

These are things we're using as an organization to really reach out to places and corners of the healthcare world that either didn't really exist before or we just never really got into because we recognize just treating people in hospitals is not going to do it anymore."

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