Improving the Health of a Population Through Collaborative ... · Improving the Health of a opulation Through Collaborative Care All 200 physicians at Crystal Run use the NextGen®

Improving the Health of a Population Through Collaborative Care

Five strategies for success

Showcasing Crystal Run Healthcare


As healthcare reimbursement shifts from volume to value,

organizations are focusing less on episodic care and more on managing population health and wellness, taking an expansive and longer-

term view of healthcare to optimize outcomes.

Leverage meaningful analytics1


As practices onboard a myriad of health information technology—electronic health

records (EHRs), data warehouses, practice management solutions, and so on—the

volume of patient data to which an organization has access grows exponentially. Being

able to thoroughly analyze this data allows a practice to fully appreciate the current health

of its population, identifying trends, patterns, and outliers that warrant further study.

Moreover, engaging in comprehensive

analytics enables risk stratification, where an organization

segments its population by care needs to better focus

resources and deliver targeted care. By drilling down

into data this way, organizations can ultimately be more

proactive in improving their patient panel’s health with

improved outcomes and reduced care costs. These are key

elements of the population health initiatives needed for

performance-based, accountable care payment models.


Consider the example of Crystal Run® Healthcare, a multi-facility physician practice

located in upstate New York with more than 300 providers representing more than 40

medical specialties. The organization is a national leader in the use and advancement

of EHRs and other health information technology (HIT) and is designated by the National

Committee for Quality Assurance (NCQA) as a level-three patient centered medical home

(PCMH) as well as one of the first accredited Accountable Care Organizations (ACOs).

multifaceted strategy.

When it comes to data analytics,

the practice pursues a


To start, Crystal Run analyzes

billing data pulled from its EHR and

matched to the master patient index,

to identify high utilizers—those patients who

are seen frequently or have certain diagnoses (such as

congestive heart failure and COPD) that, if poorly managed,

can lead to hospital admissions and/or have critical test results that

need attention, including diabetic patients with elevated A1C levels.


Once these high-risk patients are identified, the organization works to anticipate

and respond to their care needs, employing a variety of interventions that range in scope

and scale. For instance, if a patient’s condition is less critical, the practice may just reach

out to make an appointment or implement a standardized treatment protocol to drive

care. For more complex patients, the practice may assign a nurse manager who regularly

reviews the patient’s record, assesses risk factors, coordinates care, and ensures

compliance and follow-up.

By matching escalating interventions with higher-

risk patients, the organization not only improves patient care, it also allocates

its resources more effectively. A win-win for both patient and practice.


Certain types of visits, such as hospital admissions and discharges, also trigger

the practice to take action. The organization runs a daily report showing all the

patients who have been admitted to or discharged from partner hospitals. The

practice reaches out to these individuals—whether in the hospital or at home—to

assist with the transition. A dedicated Crystal Run care manager is embedded in

one hospital to smooth care transitions and help prevent unnecessary readmissions.

Depending on the patient and the intricacies of his or her condition, the practice may

even send a nurse to the patient’s home to reconcile medications, make follow-up

appointments, double-check medical equipment, and so on.


Crystal Run also reviews data to track practice usage patterns,

looking at from where patients travel when they visit the doctor and what

kinds of patients are being seen in certain locations. This allows the organization to more effectively recruit new specialists and onboard additional practice sites. For instance,

if one practice is seeing a large number of prenatal patients, then

Crystal Run may consider bringing on an additional OB/GYN to ease workload and enhance care delivery.


The practice also leverages data to improve performance. For example, last winter the

organization analyzed data to assess how well it responded to a large snow storm, seeking

ways to optimize patient care during inclement weather and limit continuity disruptions.

Multiple processes including physician snow plans, phone team scripting, and “access

Saturdays” were developed as a result of this.

For the most part, Crystal Run

elects to use billing data in its analysis efforts because of the

information’s accessibility and timeliness. While claims data

can provide valuable information about care costs, it can be

challenging to obtain, and by the time providers receive it,

it can be up to six months old. Conversely, billing data helps

the practice asses in near real time the complexity of its

patient population and who is in need of care.

Look to support interoperability 2


As more practices participate in ACOs, shared

savings models, and other risk-based payment strategies, the need

to seamlessly exchange information with multiple

diverse systems is becoming increasingly important.


Moreover, interoperable technology offers many benefits for population health management, enabling providers to:

Support the creation of a longitudinal patient record, which allows providers to look across a

patient’s care and appreciate the full picture of

treatments, medications, outcomes, and so on;

Yield better care on an individual patient basis as providers across the care continuum share

information and work collaboratively to deliver

more responsive and less duplicative care;

Offer a wider view of the population by

giving an organization a more detailed and

comprehensive picture of health needs; and

Streamline referrals by ensuring organizations

can quickly and easily share patient information

between providers.


All 200 physicians at Crystal Run use the NextGen® Ambulatory EHR, enabling smooth,

easy data sharing and interoperability within the organization. For example, a primary

care physician in the practice who shares the same patient as one of Crystal Run’s specialty

physicians can exchange information, electronically discuss care options, and work with the

specialist to deliver optimal care because both providers are able to access and interact

with the same medical record.

Crystal Run also is expanding interoperability with

organizations outside the enterprise. For instance, the

practice uses a HISP (health information service provider)

to securely transport encrypted health information, such as

pictures, reports, and continuity of care documents (CCDs),

in a standardized format to external healthcare providers.

This is especially helpful when communicating with local

hospitals and specialists that use different EHRs. Crystal Run

also uses secure email for messaging between providers.


Going forward, cutting-edge interoperability tools from NextGen Healthcare and Mirth—including flexible interoperability

interfaces embedded in the EHR—will further increase Crystal Run’s ability to share information seamlessly and securely. In the future, patient data from external sources will

directly import into a patient’s medical record, improving workflow and

efficiency while enabling better care coordination.

Offer robust care management3

Although analyzing and sharing data are key to

accountable care and a strong population health management

program, healthcare organizations cannot forget the human

element. In other words, practices must be able to turn information into action—and the key to this

effort is targeted care management.


Crystal Run has an especially strong

care management program, allocating

significant resources to that work. First,

they have dedicated care managers

in various medical homes who partner

with patients to improve their care,

sometimes visiting high-risk patients

in their homes to perform medication

reconciliation, assess treatment

compliance, and provide patient

education. These care managers also

look for potential problems that, if left

unchecked, could lead to a hospital

admission. They also work to employ

therapies that mitigate problems and

reduce the need for acute care.


The organization also embeds care managers in local hospitals to smooth discharge

transitions—a time fraught with potential risk for certain patients. These care managers

visit with Crystal Run patients in the hospital and discuss next steps for care. Before

discharge, they send information about the patient to one of the office-based care

managers so he or she can coordinate post-discharge communication and treatment.

These hospital-based care managers also send alerts to the primary care physician

and relevant specialists as the patient is being discharged.

All of this personnel investment and data exchange ensures appropriate post-discharge care and that all relevant information from the hospital is reconciled against the patient’s primary care record, preventing medication errors and complications that could result in readmission.


To further support care management, Crystal Run also has a strong home monitoring program in which nurses

watch changes in a high-risk patient’s condition through Bluetooth-enabled

scales, pulse oximeters, blood pressure cuffs, and other equipment sent

home with the patient. If the patient starts trending in a direction outside the normal range, the organization is automatically notified and can check

in with the patient over the phone, make adjustments to medications, visit

the home, or engage in some other intervention.


Although Crystal Run currently has a high-functioning care management program, the

organization is not resting on its laurels. The practice is working with NextGen Healthcare

and Mirth to develop and implement an advanced care management tool, designed

to speed informed, personalized care to patients who need it. Basically, it will function like

an electronic medical record for care managers... seamlessly integrating with existing

NextGen Healthcare software to facilitate more collaborative and cross-continuum care.

Incorporate population health management into workflow4


Managing the health of a population represents a departure from how

provider healthcare organizations have traditionally provided patient

care—as opposed to zeroing in on a single patient’s needs at a particular

point in time. To get physicians and other providers on board with this new way of thinking, organizations have to make population health management activities fit into existing workflow.


As with other aspects of healthcare delivery, if population health processes are too confusing

or cumbersome, or take a physician off track from providing direct clinical care, they won’t

be successful. Embedding population health management into workflow is about

efficiently getting providers the information they need in a format they can use.

Crystal Run uses easy-to-read dashboards and reportsto show providers information about the health of their patient population, allowing physicians to quickly see areas of

opportunity and gauge progress toward improvement. In addition, the practice hosts medical home meetings in which health

data is shared with the entire care team so everyone is on the same page about how to effectively manage population health.

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Incorporating population health management tools into the EHR is another way to embed

these activities into workflow, helping providers respond immediately to high-risk

patients when they talk to them on the phone, exchange email, or see them in the office.

For example, Crystal Run is working with NextGen Healthcare to bring “risk scoring”

into their EHR so a clinician can look at a patient record and see at a glance what the level

of risk is for readmissions, negative health outcomes, and so on. The provider can then take

action to prevent possible issues and improve patient care.

Although Crystal Run has already started manually assigning risk scores to patients, it is a cumbersome process. Automating the effort will bring critical information to the point of care faster, allowing providers to seamlessly integrate the work into daily operations.

5Engage patients


All the data, technology, and analytics in the world won’t improve the health of a population

if the patients themselves are not willing to engage in their health. For

example, you can tell someone she needs an annual mammogram and

make the appointment for her, but if the individual does not see the

value in the mammogram or doesn’t prioritize getting it done, it may not

happen. For this reason, finding concrete ways to engage patients in their health is an essential—and often elusive—part of population health management.


Crystal Run employs several different engagement strategies. First, the organization

streamlines patient access, making it easy for individuals to make appointments, ask

questions, and fill prescriptions. By offering tools such as online appointment scheduling

and a patient portal, the practice ensures patients can better communicate with their

providers and coordinate health appointments, schedule lab work, and review test results.

currently utilize the patient portal.

Nearly 10 percent

of their active patients


To further drive engagement, Crystal Run is looking to onboard a mobile app that will foster more bi-directional communication, allowing patients to

perform routine care management tasks using their phones. This

technology is just starting to take hold, and the practice hopes it will

ultimately boost patient involvement in care.


In addition to facilitating greater access, Crystal Run has instituted several outreach

programs to capture the attention of patients interested in improving their health.

For example, the practice offers meetings and educational sessions in the evenings and on

weekends for people who want to learn more about a specific topic, such as asthma care or

diabetes prevention.


One particularly creative initiative, called the “Walk with a Doc” program, educates patients while promoting heart health and exercise. Participants meet at a local park to listen to a presentation by one of Crystal Run’s doctors and then they go on a walk together. This gives patients an opportunity to build comradery with the physician, seeking information while engaging in good fitness.


fitness

changes

Looking ahead, Crystal Run is developing a patient activation project which will involve

targeted marketing to empower patients to make changes in their lifestyle and

embrace the fundamentals of healthy living. They also are considering offering

incentive programs, such as ones that involve a personal fitness tracker, to encourage

regular exercise, healthy eating, and sufficient sleep.

regular exerciselifestyle healthy eating

healthy living

sufficient sleep

fitness trackerempower

fundamentals

When data, technology, and people come together, population

health improves

As you have read, there are many ways healthcare organizations

can work to enhance their population health management initiatives. Fundamentally it comes down to

this: the more an organization is able to leverage data and technology

to segment populations, deliver targeted interventions, engage

patients, and proactively mitigate risk, the better it will be at managing

the health of its patient populations.


To do this effectively, organizations must commit to collaboration and be ready and

willing to work with other providers, vendors, payers, and patients to improve care,

elevating health and wellness across the country.

The results are telling. Crystal Run Healthcare has been able to decrease

avoidable admissions by 15 percent and decrease

30-day readmission rates by 11 percent, all while

improving quality scores across the board.

Copyright © 2016 QSI Management, LLC. All Rights Reserved. NextGen is a registered trademark of QSI Management, LLC, an affiliate of NextGen Healthcare Information Systems, LLC. All other names and marks are the property of their respective owners.

NextGen Ambulatory EHR version 5.8.2 is 2014 Edition compliant and has been certified by ICSA Labs in accordance with applicable certification criteria adopted by the Secretary of Health and Human Services. This certification does not represent any endorsement by the U.S. Department of Health and Human Services. ONC CHPL Number: 140204R01. Read more about our certifications at https://nextgen.com/Certifications

SHW2-5/16

For more information about Crystal Run Healthcare, visit www.crystalrunhealthcare.com. For more information about NextGen Healthcare’s solutions, call 855-510-6398 or visit www.nextgen.com.

Documents

Improving the Health of a Population Through Collaborative ... · Improving the Health of a opulation Through Collaborative Care All 200 physicians at Crystal Run use the NextGen®