How 3 organizations manage population health

Efforts to better manage the health of patient populations are paying off for organizations in the form of reduced costs, better patient outcomes and improved health within the community, according to Healthcare IT News.

The publication highlights three organizations--of all different types and sizes--that have made investments in population health management technologies in the transition to value-based care that resulted in improved care and outcomes.

The first--Orlando Health, a private, not-for profit healthcare network in Central Florida that includes eight hospitals with a total of 1,780 beds--created a clinically integrated network by implementing technology that the entire system could use as a single reference source for patient data. It then used the platform to target patients who met certain criteria and automatically contacted them via phone, email and text to notify them of care gaps. It also contacted their primary care provider for an appointment, and sent automated reminders about the appointments to patients.

The technology helped the system identify close to 300,000 patients with care gaps, according to the article. A year after implementing the program, the organization has seen a 22 percent increase in patients who responded to the automated messages and sought care, wrote Tawnya Adkisson, director of care coordination.

A mid-size organization also used technology to better manage its population's health with success. Marlene McIntyre, director of quality, risk and population health at Northeast Georgia Diagnostic Clinic, a multi-specialty practice of 36 physicians and 11 mid-level providers across seven specialties, said that the organization couldn't possibly manage 50,000 patients manually with its limited resources. Instead, it used a platform to build patient registries based on chronic conditions to identify care caps and perform outreach.

The technology helps ensure its patients discharged from the hospital or emergency department to home receive the necessary follow-up care and prevent readmissions, she said. It also allows the organization to better manage the care of patients with two or more chronic conditions; and review claims data with payers to identify when another provider outside its network closes the gaps in care of high-risk and complex patients. The technology, McIntyre wrote, has helped identify more than 29,000 patients with at least one care gap and contact more than 15,000 patients about follow-up care.

The third organization featured is a small independent practice in West Virginia with six physicians and two mid-level providers. Terry Coleman, administrative director, Charleston Internal Medicine, said the practice uses population health management technology to expand the number of patients in its "medical neighborhood" concept via automated daily email campaigns to remind patients about wellness visits and lab tests. Within a year of implementing the platform, the practice reports 82 percent of its population of patients age 65 and older had annual wellness exams and adolescent wellness visits increased by 146 percent.

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