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The platform took the organization's clinical, operational, and financial data and created benchmarks and comparative analytics. These reports provided its physicians with a guideline to compare their performance against their peers within a targeted population. Further, Walker says the data comparisons opened up a dialogue among physicians and helped motivate physicians to improve by encouraging better collaboration and a sharing of best practices.
The same data was used to guide a four-person patient care advocate team that Cornerstone began to ensure the success of its patient-centered medical home. Using the population-specific data, patient care advocates make calls to chronic care patients. In the first year, the team made 5,528 calls to high-risk patients, verifying whether patients were taking prescribed medications or following any other physician-ordered care. The advocate could address basic medical questions based on the electronic medical record and schedule appropriate follow-up care. The program resulted in 1,816 appointments—1,616 of which were kept.
"With population health it's important to know you can't do robocalls or email blasts," Walker says, noting that to manage a high-risk population, patients need contact with an advocate who has access to their medical data and the ability to discuss what's happening with them clinically. The advocates can identify gaps in care, encourage patients to keep scheduled appointments, and schedule follow-up visits when warranted.
While Cornerstone's medical home is still in its infancy, the results are promising; between 2010 and 2011, the organization saw a 16.5% decrease in diabetic patients with A1C greater than 9, LDL greater than130, or BP greater than 140/90. Walker says the organization attributes the improvement in these patients' health to the combination of efforts by the physician to work with the patients to educate them more about their disease and necessary treatment, and to the patient advocate outreach program.
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