A patient-centered medical home for chronic care management implemented alongside just a hint of data analytics technology is making a difference.
This article first appeared in the June 2016 issue of HealthLeaders magazine.
Human relationships and just the right application of technology seem to be unlocking population health's benefits.
Now, one healthcare system has the hard data to back up such statements.
At Houston Methodist, a seven-hospital, 1,931-bed health system in Texas, a six-month pilot implementation of a direct-to-employer population health strategy reduced hospitalizations and visits to the emergency department, says Julia Andrieni, MD, vice president of population health and primary care, as well as president and CEO of Houston Methodist's Physicians' Alliance for Quality.
Andrieni delivered the hard numbers backing up Houston Methodist's commitment at the HealthLeaders Population Health Exchange, held last week in Austin, Texas.
Her talk began with her own definition of population health: A data-driven integrated healthcare delivery model that provides individualized care plans to employees and beneficiaries based on their health risk profiles.
In the pilot, drawing from a pool of 3,000 employees, Houston Methodist moved from a mix of 28% uncontrolled and 72% undercontrolled diabetes and hypertension patients to a mix of 11% uncontrolled, 37% undercontrolled, and 50% controlled diabetes and hypertension patients.
In this study, Houston Methodist defined low risk as a hemoglobin A1C reading of less than 7, and hypertension as being below blood pressure reading of 140 over 90 or less. High risk was defined as hemoglobin A1C greater than 8, and stage 2 hypertension.
"The results were even greater for people who had home health monitoring devices," Andrieni says.
Getting to these results required basic population health measures, such as realizing that 47% of Houston Methodist's own employees in the high-risk and rising-risk group did not have a primary care physician.
"So we created physician primary care population health partners, and to be that, you had to give same-day access," Andrieni says. "You couldn't be a partner unless you could provide same-day access, because the goal was to reduce those ED visits and hospitalizations."
Many of those identified as at risk in the screenings did not know going in that they had diabetes or hypertension, and sought primary care from specialists instead of having a primary care physician of their own. Houston Methodist secured primary care for those at-risk patients, then trained the extended primary care team in techniques of motivational interviewing, "our secret sauce," Andrieni says.
"They form relationships with the patients, and we had to have a graduation program, because they want to keep those relationships going, weekly, month, forever." The team-based approach extends well beyond physicians themselves, incorporating clinical pharmacists, diabetes educators, case managers and behavioral health professionals.
Matching the population health partner with the right patient means looking at what that particular employee needs, including the languages they speak, Andrieni says.
The home health monitoring devices feed blood pressure and blood glucose readings via wireless Internet to dashboards staffed by nursing care navigators, who can stratify patients by risk, contact patients via text message or phone, and remind them if a reading is overdue, she says. If a reading is too high, these navigators can send messages to a primary care provider ahead of an office visit, suggesting that a medication be adjusted.
Houston Methodist has implemented this patient-centered medical home for chronic care management with just a hint of data analytics technology, something Andrieni is now investigating to further scale up the program. Already, one nursing care manager can manage 200 to 230 patients, she says.
Employee Motivation Wasn't Financial
As part of evaluating the pilot, Andrieni's team asked what was the prime motivator for employees to participate in the program. Financial incentives in the form of healthcare premium reductions from the HR department turned out not to be the prime motivator. "Thankfully, what motivated them was improving their health," she says. "That was great to see. And they actually felt they were more productive, because they felt healthier."
Even a full year later, hypertension and hemoglobin A1C outcomes at San Jacinto were improved. "The average hemoglobin A1C reduction was 1.3 [points], which is significant," Andrieni says.
This January, Houston Methodist scaled up the program to all its hospitals, and began to reach out to the 47% of businesses in its service area that are self-insuring the health of their employees. "In our own market for corporations, they've always focused on wellness programs, but not really on chronic condition management, so they've actually come to us," Andrieni says.
Now, Houston Methodist is proposing to offer this program as a product, as per-member per-month contracts, bypassing health insurance middlemen and itself assuming the risk for keeping such populations healthy, she says.
The technology component will invariably follow. "We are thinking about apps," Andrieni says. "We are thinking about portals. We're trying to think, what is it [patients] really want that speaks to them? Is it different for different populations? We have some work to do on that."
Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.