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How Population Health Analytics Opens Opportunities for Better Care

   November 20, 2013

Leading the way to better patient care

At Virtua Health, population health analytics from Alere Analytics is being implemented to determine the highest-risk patients from a cohort of 12,000 attributed Medicare lives, says James Gamble, MD, chief medical information officer of the four-hospital, 885-staffed-bed integrated delivery network headquartered in Marlton, N.J.

Virtua became an ACO on January 1 and is preparing to add another 14,000 covered lives with a commercial insurer, says Alfred Campanella, Virtua's executive vice president of strategic business growth and analytics.

"There are lots of different scenarios where action is needed to prevent an admission or to prevent a condition from getting worse," Campanella says. Virtua is working with Alere to publish its alert lists via a Microsoft Dynamics customer relationship management platform. "That allows care nurses to take advantage of our Microsoft products like email and word processing," he adds.

Virtua uses RNs to provide close case management of the high-risk population. Meanwhile, 80 Virtua-employed primary care doctors are kept updated via the workflow into the system's electronic health record software. "That way that doctor doesn't have to leave their EMR or jump around to see where things are going," Campanella says.

"Our initial focus," Gamble explains, "will be on these high-risk patients, so as we see it, these case managers' day-to-day job will be: They'll have a patient load, they will have care plans, they will have activities assigned to them for these patients."

But the physician does not need to be the primary manager.

"As long as patients are following care plans, which are developed and approved by the providers, then the nurses will be managing them," Gamble says. "Their communication will be more as updates. When an alert arises that the patient is at risk or in trouble, then obviously the nurse would directly communicate with the physician to try to intervene at any early stage before the patient's health deteriorates or the patient ends up in the emergency room of the hospital."

"What we're seeing now is a more intense focus to try to fix those gaps in care and to identify patients who are at high risk for hospitalization or readmission or who need special attention," Campanella says. "Technology gives you a greater magnifying glass in many respects for seeing the barriers to care and for creating efficiencies in care delivery. While all the analysis is not complete, early results for clinical and financial savings are promising."

Support from top leadership has been crucial to Virtua's transformational pivot toward analytics. "This whole idea of care coordination was approved at the board of trustees level," Campanella says. "We've had tremendous support from our CEO, Richard Miller. One of our senior vice presidents, Stephen Kolesk, MD, doubles as the president of this subsidiary that is the ACO. He has a title of senior vice president for clinical integration, so it's very tightly integrated with the physicians."

Technical design of the Virtua analytics solution is close to completion. Parts of it will deploy before the end of 2013, and other parts will roll out in the first quarter of 2014, says Campanella. Also part of the project are an existing health information exchange and a new patient portal built on top of the HIE, he adds.

"Innovation does require some experimentation and risk," Campanella says. "The ones who are leaders are taking on some risk and putting some investment in without fully understanding the full picture, but that's what makes them leaders.

"It's now the right way to care for patients, to have this high touch, high visibility into all the different domains of their care and the handoffs between those domains, and so even if the ACO concept from a regulatory standpoint goes away, it's still the right way to care for patients,"
Campanella says.

Outside the hospital walls

Organizations beyond postacute hospitals are also engaging healthcare in a variety of ways that have broad implications for how analytics will be deployed in healthcare across the United States.

Brentwood, Tenn.–based Brookdale Senior Living owns and operates about 650 senior living communities in 36 states. In 2012, Brookdale, through a partnership with the University of North Texas Health Science Center and Florida Atlantic University, received $2.8 million of a $7.3 million Centers for Medicare & Medicaid Services Health Innovations Challenge grant for population health management. The program expects to save more than $9 million over a three-year period.

Initially, Brookdale is focusing on population health at 27 communities in Texas and Florida, but by the end of the three-year grant, it will involve 67 communities, says Kevin O'Neil, MD, chief medical officer of the organization.

The CMS grant sets a goal for Brookdale of reducing avoidable hospital readmissions by 11%, O'Neil says. "We know we're going to be focusing on certain quality metrics in addition to readmissions," he says. "We'll focus on dehydration rates, as well as new incidents of pressure ulcers, some of the major problem areas in geriatric care, and then, based on the data that we receive from the analytics tool, it'll help guide our quality improvement teams in terms of the type of improvement efforts that need to be initiated."

Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.

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