Population Health Lessons From Hospitals in the U.S.' Healthiest Counties: 3 CEOs Share Successes

This content is sponsored by Arcadia Healthcare Solutions.

 Population health management is quickly becoming a fact of life for hospitals and health systems across the country. From adding a new C-suite position to taking survival notes from safety-nets, it's seems like a handle on population health is increasingly important for competency in healthcare risk management. But what's it like to run a hospital in a place where the population is already healthy?

The Robert Wood Johnson foundation published its annual list of the healthiest counties in every U.S. state in March. Here, three hospital and health system executives leading one or more facilities in these counties explain their population health initiatives in the context of their locations.

Question: What is it like being head of a hospital in the healthiest county in your state?

Judy Coffey, RN, Senior Vice President and Area Manager for Sonoma-Marin of Kaiser Permanente (Oakland, Calif.): It's an honor, and with that honor comes tremendous responsibility. Being the "healthiest" county in California does not tell the whole story. At Kaiser Permanente, we believe good health is a fundamental right of all people. We recognize that promotion of good health extends far beyond the doctor's office and the hospital which is why we have developed an extensive community benefit program to support the people, programs and services most in need. In Marin County, our community benefit program focuses on three broad areas: Providing access to high-quality care for low-income, underserved people, creating safe, healthy communities and environments where people live, work, and play and developing important new medical knowledge and sharing it widely with others to train the culturally competent health care workforce of the future.

Donald Gintzig, MBA, President and CEO of WakeMed Health & Hospitals (Raleigh, N.C.): It's an honor, and I'm humbled by our 53 year history in Wake County and beyond. WakeMed Health & Hospitals exists to improve the health and well-being of the communities we serve, which means we also have a responsibility to help our community lead healthier lives. Wake County has held the top spot for five years straight as the healthiest county in North Carolina, and number 11 on the list of healthiest capital counties in the U.S. We want to continue that trend and move up the national list, so we're all looking to raise the bar, focus on population health and continue to improve health here in Wake County with the right services in the right places. Our elected officials also adopted a new goal for Wake County this year: to become the healthiest capital county in the U.S. And I think we can achieve it.

Amy Pollard, BSN, MPS, CEO of Noyes Health (Dansville, N.Y.): In most ways, being CEO at Noyes Health is not different than at any other hospital. However, to be in the healthiest county in New York state there is a stronger commitment to working with community partners across the continuum of care. Together we identify barriers to care or patient compliance and define strategies to improve outcomes. The CEO has to lead the hospital to change from thinking about the care that is given while the patient is within our walls to thinking about the care of the patient outside our walls.

Q: How has the increased national focus on population health changed the way your hospital cares for patients? Does business?

Ms. Coffey: At Kaiser Permanente, we have always had a focus on wellness and health advocacy. Prevention is in our DNA. Long before the Affordable Care Act made the word "prevention" a health care norm, our members were receiving regular preventive screenings and encouraged by their physicians to make healthy, active lifestyle choices and stay away from harmful habits like smoking. Recently we kicked off the Fifty Thousand Quitters Campaign to get 50,000 of our members in Northern California to quit smoking by the end of 2015.

Another way we continue to evolve care is through the use of our electronic medical record system called KP HealthConnect. Our clinical experts can use KPHC to research trends in our most complex, chronically ill patients, identify successes and spread best practices in managing the continuum of their care.

Lastly, our commitment to providing high-quality, affordable healthcare at the right place and at the right time continues to change the way we do business. Personalized, convenient care requires us to expand our services into less traditional settings, including e-mail your doctor, home visits, telephone, online and video visits, prescriptions by mail and preventive apps for mobile devices.

Mr. Gintzig: We are pleased to see the nationwide shift toward a system of health, not just healthcare. For patients, we are already leading the shift to a new model of care by forming an ACO. WakeMed Key Community Care is a physician-led effort in partnership with the hospital to provide integrated, patient-centered care. This means coordination of care, more involvement in prevention as well as a more active role in helping people manage their overall health outside of the healthcare setting. From a business standpoint, we've invested significantly in evolving our organization to provide effective, accessible healthcare long into the future. Probably the best example of this is our implementation of the Epic electronic patient record system, which marks WakeMed's largest single information technology investment to date. In our view, electronic records are a vital part of patient-centered care and crucial to managing population health.

Ms. Pollard: We no longer see ourselves as a standalone organization, but rather as part of the region's broader healthcare ecosystem. So, we work closely with area physicians, other hospitals, nursing homes and rehab programs to help patients maintain their health. As a result, we have more conversations with care partners in order to ensure consistent quality, effect a seamless transition and, of course, to keep the patient at home or at the most appropriate level of care possible. In terms of our business, we continue to see the transition from inpatient to outpatient revenue. Currently, 75 percent of our revenue comes from outpatient services and I expect that to grow.  

Q: Describe the process surrounding population health planning at the hospital, if there is one. What are the most important focus areas?

Ms. Coffey: Just as our focus on total health — integration, prevention, and empowerment — drives internal planning for our members, it also drives planning for improving the health of our community. For example, every three years we conduct an extensive community health needs assessments to better understand the changing demographics, challenges and needs within our community. The CHNA process informs our community investments and helps us develop strategies aimed at making long-term, sustainable changes. The process also allows us to deepen our relationships with community partners, including educational and governmental entities, other nonprofit organizations and safety net clinics. Through these partnerships, Kaiser Permanente strives to benefit the community by addressing issues and concerns that affect overall community health, such as healthy eating active living, mental health, substance abuse, and access to care. Kaiser Permanente is also very proud to partner with Partnership HealthPlan California a managed Medi-Cal care provider, to provide free and/or low cost coverage to more than 40,000 members in Marin, Sonoma, Napa and Solano Counties.

Mr. Gintzig: Planning and decisions are made at all levels, from finance to quality to patient care and physician leadership. We're aligning our efforts to transform healthcare through partnerships and by helping our patients take charge of their health. We are focused on the areas that are also challenging the healthcare industry as a whole:

Increasing quality, safety and services, decreasing costs and shifting to a culture in which we try to keep people healthy and out of the hospital. Through coordinated care, innovative programs, robust acute and rehabilitative services as well as community physician partnerships, we have a unique opportunity to help our neighbors get and stay healthy.

Ms. Pollard:Population health management can only occur with planning and cooperation within the region. Noyes is a collaborating institution of the University of Rochester (UR Medicine) and is a participant in the Accountable Health Partners network established by UR Medicine. AHP brings together academic and community providers who work together to improve quality, access and cost efficiency. Areas of focus for population health are the obvious ones of chronic disease management and preventive health services. Livingston County is a rural county with the primary industry being agriculture so it is critical to have services in multiple sites and to have strong public health and home health programs.

Q: How does your hospital integrate your employed and affiliated physicians in the planning and execution of population health initiatives?

Ms. Coffey: Through Kaiser Permanente's uniquely integrated model — Hospital, Health Plan, Medical Group — we are able to bring together representatives from all aspects of the healthcare delivery system when planning and executing initiatives, including our network of more than 17,000 physicians. In the community, our physicians also bring a valuable medical voice to various population health initiatives, such as increasing regular physical activity, providing access to healthy affordable foods and creating a broad network of community connectors and support services. In Marin [County], 25 of our physician leaders serve on 32 local, state and national committees and boards.

Mr. Gintzig: You can't achieve population health without bringing everyone to the table. We all work together to complement each other's services and ultimately create a healthier community. It's this collaboration that will continue to lead us toward a system of health, not just health care.  

We directly employ more than 250 exceptional physicians covering primary care and over 20 specialties through our WakeMed Physician Practices division. We support our growing network of engaged physicians and ensure their needs — both employed and otherwise — are represented and met as we look for new ways to work together to care for patients in an era of healthcare reform.

WakeMed Key Community Care (the ACO) brings together more than 220 independent primary care physicians from Key with a leading health system and another 250 primary care and specialty providers from WakeMed Physician Practices. This new endeavor represents another step forward in our efforts to work closely with physicians to improve access and quality and provide higher-quality coordinated care in our area and across the state.

Ms. Pollard: Educational presentations are offered to both groups at same time. There is also a routine meeting of all (employed and affiliated) office staff as they are key to implementation.

Q: In terms of population health, what types of data are most important for your planning and execution? Claims? EHR? Labs? Others?

Ms. Coffey: Our electronic medical record system is our most powerful internal tool. It allows us to draw data from our 9 million members to identify trends, research best practices and, ultimately, improve health outcomes. For our community health needs assessment, we work closely with the county and state public health departments, reviewing various sets of data, including mortality and morbidity data, as well as substance abuse, drinking, and tobacco consumption figures. With a commitment to our young people and thriving schools, Kaiser Permanente works closely with the Marin County Office of Education to review and analyze student behavior data surveys to support and encourage healthy food choices on and off campus, as well as raise awareness and minimize high-risk behaviors, including binge drinking.

Mr. Gintzig: All of these are important. Data helps us identify those patients who are using extensive resources within the health system and analyze why. For example, if a patient has repeated emergency department visits due to unmanaged diabetes, we can identify the issue and then work with care managers and primary care physicians to help the patient manage his or her health. Our system-wide electronic record implementation will further help us capture this data and alert caregivers before the issue is trended in claims data.

Ms. Pollard: An annual community health needs assessment is completed every three years in partnership with our rural health network that includes county health data, behavioral risk factors, community survey and focus groups. This information is used to create the Community Health Improvement Plan that identifies the top healthcare priorities in the county. Once these priorities are defined, we can drill down on the utilization of services and identify opportunities to improve healthcare outcomes in the most cost effective manner for the system.

Q: What best practices for population health have you found in your hospital? How do you distribute those best practices to the community of providers and patients?

Ms. Coffey: Not only is Marin County one of the healthiest counties in the country, it is also one of the oldest. One in four adults in the county is 65 or older — higher than the California state average and the nation. We at Kaiser Permanente believe that prevention is for young and older adults alike. We are committed to improving heart health and working to both prevent heart attacks among our members, as well as improve the outcomes for patients admitted with serious heart attacks. Over a 10-year period, our Preventing Heart Attacks and Stroke Everyday efforts have resulted in a 24 percent decrease in heart attacks and a 26 percent reduction in stroke mortality, and today, Kaiser Permanente Northern California members have a 30 percent lower risk of dying from heart disease than the general public.

Another example: Every Body Walk! is a campaign created by Kaiser Permanente to get Americans up and moving. We realize to be effective we have to go beyond saying "you need to walk more, or be more physically active," so our physicians have begun writing walking prescriptions for patients. In turn, we are beginning to connect patients with safe, convenient, affordable community resources that support walking and physical activity.

Mr. Gintzig: The more you know about your health, the better equipped you will be to manage your health.Healthcare systems and providers play a crucial role in promoting, providing and educating patients about preventive services and screenings and maintaining their health. WakeMed treats more heart patients than any other hospital in North Carolina. Through support programs, like our congestive heart failure program, we are able to work closely with our heart patients and their families to minimize risk for hospitalization and manage their conditions.

We established the CHF program in 1999 — a time when follow-up care was an unexplored area. Between 100 and 150 phone calls are made each day as part of the program's follow-up care. And the patients are listening. The percentage of CHF patients returning within 30 days was 14 percent in our latest reporting period, and we've been as low as 10 percent. 

Additionally, having accurate information about a patient's primary care provider is necessary for coordinating care across the healthcare continuum. This concept of coordinated care is especially important for successful population health programs, like the WakeMed Key Community Care ACO. Our goal is to provide the best care for patients during an acute episode and return them to their primary care physician for follow-up and preventive care.

Ms. Pollard: Within the last year, the hospitalist group for Noyes became the medical providers for the Livingston County Center for Nursing and Rehabilitation, a 262-bed facility. Prior to this change, data demonstrated a higher than average readmission rate and possible preventable admissions. Having a single group manage the residents at both sites improves continuity of care, is anticipated to decrease admissions and also decrease length of hospital stay. A Continuum of Care Coalition, which includes representatives from over 30 healthcare and human service agencies, was started this year. The goal of the group is to improve communication, increase awareness among providers of available services and address barriers to health care.

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