One health system, two populations: Centura Health's story

When it comes to population health, each stratification or subset of individuals has its own requirements and needs. So when a multistate health system launches a population health initiative, a one-size-fits-all approach just doesn't cut it.

Centura Health, a system including 16 hospitals throughout Colorado and Kansas, spans a diverse geographic and patient population. Headquartered in Englewood, Colo., some of the system's hospitals are 30-bed facilities in rural areas while others have several hundred beds in the middle of an urban metropolis. So when Centura started thinking about a population health initiative, leaders knew they had to tailor their overarching program to meet specific needs of specific populations.

In 2011, Centura identified reducing readmissions, specifically among patients with chronic conditions, as a priority. The system participates in CMS' Comprehensive Primary Care initiative, and it started to transform its primary care practices into patient-centered medical homes.

From there, Centura used existing health IT systems to advance its population health efforts, both by using existing EHR fields and creating new workflows. "The team leveraged little-known or rarely used fields that already exist in the EHR to record essential information in a structured manner to facilitate risk scoring and identification of patients who would receive intensive interventions," says Louise Schottstaedt, MD, CMIO of Centura Health. "We also created unique documentation processes so that all caregivers could easily identify the care coordinator's interactions with the patient."

On top of this, Centura Health used different elements of the EHR and these documentation processes for their rural patients and their urban patients.

"Rather than instituting one population management program for all parts of our system, we took the approach that there may be more than one way to be effective in this new space," Dr. Schottstaedt says. "The population health project in our rural area is designed and staffed to accommodate the needs and resources of the geographic area, while the methods and activities in the metropolitan area were designed with a different set of needs and resources in mind."

In Centura's rural population health project at Mercy Family Medicine in Durango, Colo., the system used daily and periodic reporting of patient care activity to aid care coordinators in monitoring care quality. Additionally, Centura worked with payers in the state to develop a claims-based activity report and reporting structure that has helped identify at-risk individuals.

The steps and challenges were different in Centura's urban project area, a large-scale accountable care organization project involved in the Medicare Shared Savings Program. Centura participates in seven ACOs, covering approximately 270,000 individuals. In this project, Centura had to link numerous data sources together. "We must find a way to manage a population across many EHRs," Dr. Schottstaedt says. "We have aligned our core EHR documentation with other electronic tools such as a proprietary risking tool; we have developed interfaces for demographics and claims data from a variety of sources; we have heavily supported enhancement of our [health information exchange] capabilities to support interoperability; and we have not forgotten the human element in this very large project."

That "human element" is the medical director of accountable care programs who is personally involved in building community among providers and works hands-on to ensure top quality care, according to Dr. Schottstaedt.

In the three years since implementing the population health projects, Mercy Family Medicine has reduced hospital admission rate for ambulatory care sensitive conditions by 27 percent. In the ACO project, Centura reduced readmissions for heart failure by 15.65 percent. The health system earned a HIMSS Davies Award in 2015 for its advancement and achievements in patient outcomes by using health IT.

Centura Health continues to learn from its population health project to determine what does and does not work. It's a process Dr. Schottstaedt says is likely to continue and requires flexibility and a new way of thinking.

"Health IT has traditionally been built for single, face-to-face encounter-based care. Clinicians have until recently been trained to be experts in only that traditional care model," she says. "But as our society redefines the scope and expectations of healthcare, health IT and clinical caregivers have to…find ways to thrive within the new design."

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