Where Advocate Health's population health strategy has changed — and where it's going in 2024

From the launch of ACO programs to system-wide infrastructure improvements, Advocate Health made a lot of changes to its population health strategy last year, and the Charlotte, N.C.-based health system has even more planned for 2024, according to its Chief Population Health Officer, Terry Williams.

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Question: How has population health strategy at Advocate Health changed the most over the last year?

TW: Our population health strategy has changed and evolved over the past year in several ways.  Following the formation of Advocate Health in December 2022, the Population Health organization was reconfigured in 2023 to operate at the Advocate Health Enterprise level to allow best practices to be identified and made available across the 2.3 million lives that we proactively support for better health.  While priorities and methods are adapted in local contexts, this level of scaled infrastructure and leadership is designed to actively support the practices of our participating 13,000 physicians across 12 clinically integrated networks and accountable care organizations. 

Our strategy evolved during 2023 to enable us to use our large scale to benefit more patients and providers.  For example, we are installing infrastructure/processes/IT to be able to simultaneously pilot and track the efficacy of changes in practice and process in dozens of places at once.  This capability is in support of our goal of adopting the latest practices in a fraction of the time of the national average from innovation to adoption.  Without concerted effort and methods like these to accelerate adoption, can you believe the national average for elapsed time from innovation to spread and adoption in this country is 17 years!

We were honored to launch two ACO REACH programs during 2023 serving almost 30,000 patients and their providers to enable us to more effectively close both care gaps and social drivers of health needs (transportation, food insecurity, social isolation, etc.) particularly among patients experiencing health disparities.

Q: What initiative are you most excited about for 2024?

TW: In 2024, we are building on our momentum in the most recent year of cumulatively saving the federal government $128 million across our MSSP programs by mobilizing our teams in several areas.  For example, we are more tightly integrating our academic research agenda to our enterprise priorities to improve the health of the population.  As an example, our approach with a chronic condition like diabetes is that we utilize a variety of methods to improve health that are tailored to about a dozen different diabetes phenotypes.  The methods range from utilizing social networks physically and through an app, digital phenotypes, coaching, access to healthy food, and AI with sensitivity to individual patient preferences, social drivers of health needs, and cultural contexts.

We are activating and spreading innovations to benefit seniors.  For example, the use of the Electronic Frailty Index (eFI) is being expanded across all markets of Advocate Health.  This measure, invented at the Wake Forest School of Medicine Sticht Center for Aging, incorporates 52 data elements to provide our most accurate insight for future care needs for EACH patient.  No other algorithm is as predictive as this one.  In addition, our hospital at home program, which is the largest in the country, is being expanded further to benefit more of the appropriate patients.   And our remote patient monitoring (RPM) capabilities will continue to expand to more markets as part of our joint venture with Best Buy Health.  We embrace the unique benefits to a variety of patients and caregivers of being remotely monitored and receiving care in the home.

We are also applying in 2024 to participate in the new GUIDE Model from CMS to deliver supportive services to a rapidly growing number of patients with dementia and their historically unpaid caregivers.  This new innovative program will utilize a comprehensive package of care coordination and care management, caregiver support, respite services and alternative funds flow to allow patients to stay in their homes and communities while supporting the caregivers, who are often family members that are overtaxed by the responsibility.  We are building on the extensive Aging & Alzheimer’s expertise in the Wake Forest School of Medicine to rapidly adopt and learn in this program in a market with plans to expand across the health system in subsequent years.

In summary, we are enthused to be actively working in 2024 with CMS and a variety of payers, vendor partners, and academic experts to provide innovative, value driven protocols and technologies to tens of thousands of our patients, regardless of where you live.

Terry G. Williams is Chief Population Health Officer – Strategy & Partnerships at Advocate Health.

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