Taking a Patient-Centered Approach to Population Health Management

As healthcare shifts from episodic care to value-based health management, hospitals and health systems must take a more proactive approach to engaging patients — especially those with chronic disease who represent a higher risk for those organizations pursuing a risk-sharing model. While population health management is a popular industry buzzword, many healthcare organizations are still grappling with how to effectively empower patients and implement reliable chronic disease management and wellness care.

Two years ago, Reid Hospital & Health Care Services — a 223-bed nonprofit hospital located in Richmond, Ind. — began tackling this issue, pursuing a population health management initiative focused on individualized patient-case manager interactions. What follows is a brief description of our program and the benefits Reid Hospital has realized since starting the journey.

Empowering patients
The cornerstone of Reid Hospital's approach to population health management is direct patient engagement with individuals at risk for hospital admissions and readmissions. The idea is that in order to limit readmissions, we have to collaborate with patients to prevent unnecessary admissions first. We found that waiting until a patient is admitted to realize he or she is high risk for readmission already puts us behind the curve with regards to proactive health management.

To connect with patients, Reid Hospital repurposed some of its RN case managers to work in the health system's physician practices, engaging with a pool of patients that have higher than average resource consumption and emergency department use, as well as an increased likelihood to be admitted to the hospital. The case managers — called disease or transition navigators depending on whether they help patients manage their chronic condition or successfully traverse different levels of care — connect with patients in person, striving to understand and resolve each individual's unique barriers to care.

To start the process, a navigator partners with a patient's primary care physician to set the stage and gain patient approval for the interaction. The navigator might then follow-up via phone, visit the patient's home, accompany the patient on lab visits, doctor's appointments and so on to ensure the patient is proactively managing his or her care.

Lessons learned
Meeting with at-risk patients has taught us some unexpected, important lessons about patient compliance with treatment plans. Some organizations assume that if they provide treatment plan information to a patient at discharge and the patient is not compliant, there is a problem with patient execution or willingness to comply. What we've found, though, is that this assumption is often false and there is some other reason the individual is not compliant, whether that is a lack of understanding of the treatment plan, insufficient resources to contact for questions or some other contributing factor.

Here's an example to illustrate the point: We recently began working with a Reid Hospital patient who has congestive heart failure, a long medication list and a history of frequent hospital admissions and readmissions. On paper, the patient seemed to be uninterested in following her care plan. However, once one of our disease navigators met with her, the navigator uncovered several reasons for noncompliance that were out of the patient's control, including confusion surrounding medication compliance. What the navigator found was that the patient's diuretic medication was a small white pill that looked very similar to several other medications she was taking, leading to confusion about which pill to take for which condition — and when. As she did not want to inadvertently take too much medication, she regularly did not take the diuretic at all, which led to many of her complications. After making this discovery via the navigator program, we met with the patient and engaged a family member to sort medications to help her better manage them. Whereas she was almost an invalid before, this simple engagement with the navigator has changed her quality of life — she is now much more active and has a lower risk for being readmitted to the hospital.

Identifying at-risk patients
To assist navigators in determining which patients warrant direct interactions, Reid Hospital has worked to uncover common characteristics among its high-risk patients. A key part of this process involved conducting an internal survey of readmitted patients, which showed that many had several comorbidities, such as heart disease, kidney problems or lung disease as well as diabetes. Extrapolating the results to the organization's patient population, the combination of various conditions with diabetes seemed to present more risk than each condition on its own, making the patients with multiple comorbidities more likely to be admitted or readmitted to the hospital for serious health issues. To date, these kinds of patients have been the primary targets of the navigator program.

Going forward, Reid Hospital plans to develop more specific criteria to segment its population into one of three risk categories — low-risk, high-risk and the potential to become high-risk. This will allow the organization to customize different care approaches to keep patients healthy regardless of risk level.

Leveraging technology
Meeting with high-risk patients is not the only way Reid Hospital approaches population health management. The hospital also uses an electronic population health tool to query which clinic patients have not had an annual wellness checkup and contact those patients to schedule visits. This allows the organization to reach out to low-risk and high-risk patients alike and transition them into proactive care. Additionally, Reid Hospital plans to use the tool to identify populations with chronic conditions for which regular interventions are known to improve quality and reduce the likelihood of patients becoming high-risk. For example, the technology will help the hospital track hemoglobin A1C measurements for diabetic patients and proactively alert patients when any anomalies are detected.

The organization also uses a patient portal to enhance patient-provider communication. Through this tool, patients can schedule appointments, check test results and send questions to their provider.

The key is getting started
Since most healthcare organizations are still reimbursed under a fee-for-service model, the need to create and implement a population health management program may not be a top priority for hospitals. However, we believe it is important to begin work on this type of program instead of waiting for payment models to change. Outcomes-based reimbursement is the future, and organizations should get out in front of it, so they are fully prepared when the time comes.

Getting started does not have to be hard or expensive. We began our program by creating three navigator positions and piloting them among a small group of at-risk patients. Even if the program was not successful, the organization could easily retask these positions into other areas, so the financial impacts of failure were low. As it turned out, the program has been beneficial and we are expanding it, hoping ultimately to have 12 navigators on staff.

Moving the needle toward population health management
Reid Hospital has seen some meaningful improvement as a result of its individualized approach to population health management. Those patients touched by the navigator program have had less emergency room visits and fewer hospital admissions and readmissions. This has translated into significant savings for the organization in terms of resource use.

While the hospital is still at the early stages of population health management, we hope that taking this patient-centered approach over the long-term will not only improve the quality of life for high-risk patients but also enhance the health of the organization's patient population as a whole.

Thomas Huth, MD, is the vice president of medical affairs, and Jason Blunk is a project manager, at Reid Hospital & Health Care Services.

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