Population Health Pays Off for NY Collaborative

A pioneering population health initiative launched by NewYork Presbyterian Hospital years ago—an experiment in care delivery at the time—has reduced 30-day readmissions by 36%. And that's not all.

Healthcare delivery is evolving so quickly that looking back a mere five or 10 years ago is like gazing at old sepia photos, quaint reminders of a long-gone era.

In 2008, for example, NewYork Presbyterian Hospital launched a pioneering population health initiative well before the concept of population health became commonplace. The rationale way back then for creating the Washington Heights-Inwood Regional Health Collaborative seems blindingly obvious now, but it's worth reviewing.

J. Emilio Carrillo, MD, MPH, vice president of community health at NewYork-Presbyterian Hospital and an associate professor of clinical medicine at Weill Cornell Medical College, was in on the ground floor of the collaborative that now provides care to about 205,000 people in the Washington Heights-Inwood section of Manhattan.

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"For a long time our emergency room was the primary source of care for so many people and we saw that it didn't make any sense. We needed a better infrastructure for providing care," Carrillo says. "We developed a model that could provide better care using the right settings for the care and improve health and even reduce costs. We felt that providing care in the emergency room was just not right."

Beyond responding to acute care needs, the collaborative was looking for a way to identify, monitor, and treat chronic health conditions in the community before the problems required hospitalization.

"We're an academic medical center. We practice evidence-based medicine," Carrillo says. "We felt we needed to study the needs of the community scientifically and analyze what the needs were and determine what we had to do to meet those needs and scientifically measure the quality of the results and make that an ongoing process."

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By 2010 NYP and collaborative partner Columbia University Medical Center and its medical school had identified key drivers of healthcare utilization and cost within the predominantly poor and underserved Latino neighborhoods they serve. The leading maladies included diabetes, asthma, heart failure, depression, and childhood obesity. The collaborative created seven patient-centered "medical villages" at clinics across WHI, and plugged patients and providers into a common electronic health record that tracked medical histories and care delivery for each patient.

Better Tools
"We maximized our use of information systems and information technology. We implemented culturally competent strategies. Those are the two keystones," Carrillo says. "We worked with Microsoft and they had developed a data aggregator that can look for diabetes. Everyone who has touched our clinics that has a diabetes diagnosis gets pulled into this registry."

"Once you pull in the individual's record number that pulls in lab results and records of utilization of ED and inpatient services and all elements of electronic medical record we designate. We are able to pull in all the data on all the diabetics we have access to."

It wasn't enough to simply identify, for example, the diabetics in their patient base. Carrillo says the collaborative designed extensive community outreach to ensure those diabetics got the care they needed.

"We instituted interdisciplinary teams that are at the heart of these medical homes," he says. "Using the IT and embedding nurse care managers into these teams we were able to identify diabetics who have not come to clinic for six months, who've been to the ED at least once, and who have hemoglobin A1c greater than 9. Hit the button and you get 50 names. We go after them."

The care teams rely on "culturally competent" health workers who live in the community and who can visit patients in their home and engage them in their own care.

"We have diabetes educators, social workers, psychologists, nutritionists, besides the traditional doctor and nurse and of course the nurse care manager," Carrillo says. "We have team meetings once a week and prepare for the people coming for the following week who have any one of these risks."

"We identify the people who have the risk of diabetes, stratify them by risk depending upon lab results and if they are using our system effectively, and we employ a team to bring them in line to control their disease, doing it all at once, using best practices, and putting them to work in concert and making the most of IT and culturally competent human resources."

Lower Readmissions, Higher Satisfaction Scores
The results have been impressive. The collaborative has reduced emergency department visits by 29%, and hospital admissions by 28% for patients with diabetes, asthma, or heart failure. In addition, 30-day readmissions and average length-of-stay declined by 36% and 5%, respectively, and patient satisfaction scores improved across all measures.

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Beyond the hospital and clinic walls, the WHI collaborative outreach program includes a network of school-based health clinics connected to the medical village by information technology that provide mental health and primary care services to more than 7,000 students. The collaborative's childhood obesity prevention program, Choosing Healthy & Active Lifestyles for Kids (CHALK) program is now in 225 schools in 42 states after becoming a model for first lady Michelle Obama's Let's Move! Active Schools program.

The success of these programs has not gone unnoticed. Earlier this month the Association of American Medical Colleges awarded NewYork-Presbyterian Hospital with its Spencer Foreman Award for Outstanding Community Service.

There is nothing that Carrillo said when I spoke with him that I haven't heard dozens of times before about population health. It's important to remember, however, that what now is common sense and commonplace was less than a decade ago an outlier—an experiment in care delivery.

It's understandable why providers get depressed and frustrated amid the everyday issues that plague healthcare delivery, the various snafus and political haggling over Obamacare, the challenges of HIT interoperability, etc. The list of challenges is long, the problems seem endless and insurmountable and beyond the control of most providers.

When you take the long view, however, programs such as the WHI collaborative demonstrate that care delivery is improving, and at a fairly good pace too.