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Driving targeted patient care: Taking a holistic approach to analytics

By Cliff Frank and Sanjay Seth, MD

Despite the maturing sophistication of data analytics tools, many practices and clinically integrated networks (CINs) still struggle to capture data from the perspective of the entire organization and provide patient-specific insight into practice patterns and performance improvement opportunities.

Shore Quality Partners, a Somers Point, N.J.-based CIN comprised of 240 independent, employed and contracted primary care physicians and specialists, faced this challenge. Shore’s leaders sought an innovative way to view resource utilization across their 35,000-member population.

With the downturn of Atlantic City’s gaming industry in recent years, the Somers Point community had experienced its share of hard times. More than 15,000 jobs were lost, exacting an economic toll on Shore’s patient population.

Medicaid participation — largely driven by Medicaid expansion—increased fivefold, and many patients had not seen a primary care physician in years. The patient population was so far detached from regular medical care that patients routinely visited hospital emergency departments (EDs) for non-urgent illnesses such as headaches, gingivitis and lower back pain.

Adopting a holistic approach

Shore decided to move from a traditional care delivery model to a holistic approach to address its patients’ physical, psychosocial and emotional needs. Shore’s leadership team rolled out a technology-based strategy to analyze patients’ health status and needs across all of its practices.

Clinical, financial and operational data from physicians’ disparate systems were captured, normalized and aggregated in a central repository. Shore then worked with all physicians, including those lacking an EHR system, to help them acquire and install technology in support of its first CIN for data exchange.

By providing a new analytics and predictive modeling platform to physicians and medical staff, Shore generated a unified view of comprehensive population data for all care settings, including the ED and urgent care, a standalone hospital, a multi-facility health system, physician offices, outpatient testing and dialysis facilities. Armed with the relevant knowledge, administrators tackled two goals:
• Reduce avoidable and expensive encounters through early intervention.
• Address beneficiaries’ social and behavioral challenges to reduce the impact on their physical health.

Reducing expenditures and improving health through care coordination

In two years, using the analytic data, Shore has identified patient groups posing the greatest opportunity for outcome improvement through better care coordination and interventions. The organization’s risk stratification model evaluates patient health based on diagnosis, comorbidities, demographics and health expenditures. Shore then targets high-risk and rising-risk patients who warrant closer medical attention.

For example, Shore identified diabetic patients with high HbA1c levels who were not seeing an endocrinologist and secured the proper referrals. Shore’s diabetes educator also visits 20 different practices monthly to meet with patients. This focused outreach makes visits more convenient and effective for patients. The network plans to use its analytics tools to stratify, connect and schedule even more diabetes patients for office visits and education sessions.

Shore staff members are also alerted to ED visits and inpatient discharges. These patients are actively engaged in transition-of-care activities and, if appropriate, care
management programs that promote pre-emptive outpatient visits. Analytics revealed that high-frequency ED patients were costing the CIN $3 million to $5 million in annual expenditures. Through targeted care practices, Shore reduced that spending by $1,600 per member per month (PMPM).

Shore’s patients now outperform the geographic comparison
group by:
• Reduced costs of $27.97 PMPM (equal to annual savings of $5.37 million)
• 15% net decrease in inpatient utilization rates
• 3% increase in primary care visits, because of increased communication with physicians

To improve its population’s overall health, Shore moves care management activities into the primary care physician’s office as often as possible. This initiative includes reaching out to patient members lacking routine annual visits to support screening and prevention activities. Medicare patients especially find their one-on-one encounters with doctors more meaningful. They report gaining a greater understanding of their disease processes, medications, and health and wellness management strategies. Throughout its efforts, the Shore network has maintained a 90th percentile ranking nationwide in patient satisfaction measures.

Moving social determinants of health to the front lines

Analytics helped Shore’s medical staff establish new clinical care protocols and resources to better manage the psychosocial aspects of patient health and wellness, and to provide 1,250 non-billable care encounters that have had a remarkable impact on overall costs. Important psychosocial aspects of the CIN’s patient population were better supported through patient engagement and wellness outreach efforts, helping the system migrate from reactive to proactive care. Staff addressed social factors that resulted in significant health advances:
• Resolved health literacy challenges by walking diabetic patients through a grocery store to discuss healthy, low-cost food choices
• Overcame knowledge barriers by meeting with patients and pharmacists to review medication lists
• Sent alerts to patients via mobile devices
• Provided bilingual support staff to bridge gaps between patients and providers
• Engaged social workers to help patients secure jobs and transportation for medical care
• Collaborated with free community resources to resolve basic needs, including Meals on Wheels,
• behavioral health, drug therapy, job placement counseling and education

Strategies to help physicians get on board with analytics

The transition from a couple hundred practices operating independently to an integrated network making unified decisions is a radical step toward value-based care. The question most asked is, “What will our doctors do together that they won’t do individually?”

Data became the catalyst to credibility in driving longterm change, compelling the CIN to evolve carefully and incrementally to build trust. For any large-scale data integration project, the strategy starts with reliable data. Accurate data debunks myths and sets the bar. It sparks and moves crucial provider discussions to fact-based decisions.

Shore offers the following recommendations to help physicians become comfortable with data analytics:
Focus on the everyday. Shore culled its data from day-to-day episodes, rather than generalized analytics. While insights that highlight gaps and patterns across the network will catch everyone’s eye for the moment, it is the patient- and provider-specific data that holds
providers’ attention over the long haul.

Think baby steps. Instead of giving your physicians an entire population assessment, start by sharing six patients and three specific steps designed to improve the health status of the patients they are seeing in the office today. Provide small doses of specific data with targeted direction they can accomplish in short intervals instead of overwhelming “dump trucks full of data.”

Empower doctors with interpretive dashboards

Shore has successfully promoted clinical guidelines and higher quality care coordination among providers by empowering them with tech-enabled clinical workflows that prioritize care to at-risk and rising-risk patients. Additionally, now that data holds their clinical performance accountable, doctors can use the regularly generated reports that are custom-built, intuitive and actionable within their practice.

Show me the data. Shore sought to change physicians’ behaviors, referral patterns and ideas about what constituted the responsibilities of a primary care practitioner. Reshaping physicians’ perceptions is predicated on sharing data to tell aggregate stories of needless spending, care gaps, quality metrics and utilization of facilities — all contributors to generating extraneous costs for uncertain value.

For nearly a year, Shore tried different techniques to convince physicians to use its care coordinators to help attend to difficult patients. It was not until credible data comparisons pinpointed care gaps, risks and other actionable items that doctors changed their mindsets. The data findings listed specific areas where medical staff could effectively improve primary care.

Shore is expanding its single data platform and infrastructure to become a risk-sharing accountable care delivery model. Buoyed by success, Shore physicians will be ready to take on higher levels of management regarding resource utilization and the health of new chronic disease populations.

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