Controlling costs & improving outcomes with population health management

In the quest to improve patient health outcomes and lower costs, one of the biggest challenges providers face is harnessing an organization-wide view of data to identify performance improvement opportunities.

Many struggle integrating data from disparate systems onto a single, comprehensive platform that supports population-level analytics. Few have success stories in reaching an effective population health management strategy.

New Jersey-based Allegiance ACO was facing the same problem. The multi-specialty physician network provides services to economically disadvantaged patients in underserved communities in Trenton and the surrounding Mercer County area. The ACO was eager to find a way to identify and proactively engage more high-risk patients in clinical best practices; however, it struggled to centralize the data that would lay the groundwork in accomplishing that goal.

Motivated by the rising impact that chronic care management was having on the ACO's budget, Allegiance leaders elected to invest in a population health management technology solution. Through the following steps, the ACO was able to move past data silos and transform participating physician practice operations.

Establishing a solid data foundation
Allegiance laid the groundwork for their population health management strategy by implementing an enterprise-wide platform to capture, normalize and integrate clinical and financial data from diverse ambulatory and acute electronic health records, claims and ancillary systems.

Deriving actionable insights through analytics
With a robust view of operational data in place, Allegiance used analytics software to identify patient groups that posed the greatest opportunity to reduce utilization through care coordination and management activities. Using a risk stratification model that weighted patient costs against diagnosis, comorbidities and demographics, the ACO was able to target high-risk and rising-risk patients who warranted closer medical attention.

Recognizing social and behavioral influences on health and wellness
Allegiance ACO has had a major impact on the health of its population through its focus on the cultural and socioeconomic needs of patients. Care coordinators seek to understand barriers to care for the organizations sickest members through direct outreach and the use of a Social Determinants of Health assessment tool. Allegiance ACO's efforts to uncover social conditions that impact a patient's ability to access information, secure transportation to dialysis treatments and procedures, and include working family members in physician office visits has reduced the number of emergency visits and improved quality of life for its patients.

Responding with data-driven care prompts
Armed with new intelligence detailing care delivery gaps, Allegiance provided physicians with granular, patient-specific care management prompts to focus their attention on patients that required their immediate attention to avoid further deterioration in their health. Workflow management tools helped care coordination teams intervene to circumvent costly medical procedures or hospital admissions down the road.

Achieving Results
Aided by their population health management strategy, Allegiance ACO generated roughly 6 percent or $2 million in cost savings among its 3,000 beneficiaries in 2015. It ranks among the top 12 pioneer ACOs initiated in 2014, accruing the most federal savings for Medicare patients.

Allegiance ACO's large-scale data integration project laid the groundwork for the development of a collaborative care coordination program that resulted in nearly $1 million in shared savings. That savings led to the hiring of three care coordinators who tracked approximately 800 high-risk patients and delivered patient-specific interventions. The average annual patient's cost dropped by about $700. Allegiance credits this spending reduction to a decrease in unnecessary emergency department visits, hospitalizations and other high-expense care services.

The ACO's population health management technology acquisition also solved the critical challenge of consolidating data across all physician members using multiple EHR vendors – averting the costly expense of implementing a single EHR technology to reach this most fundamental step in achieving true population-level analytics.

Allegiance's data-driven program inspired new care management approaches, drastically reducing costs and producing significant efficiencies in patient care management and resource utilization. By implementing a data management infrastructure that supports high-risk patient care programs in conjunction with tools designed to drive smarter workflow, providers can reallocate limited resources to achieve better outcomes.

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