How one rural hospital is rethinking population health management

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Community input and redirecting emergency care patients into patient-centered medical homes (PCMHs) are vital to improving population health, Carolinas HealthCare System leaders told Hospitals & Health Networks in a video interview.

When Carolinas HealthCare System Anson, a hospital in Wadesboro, North Carolina, conducted its community health needs assessment, it found work needed to be done in several areas, particularly in the area of chronic illness, Anson Assistant Vice President Gary Henderson told H&HN

The assessment also found high levels of obesity and diabetes in the community, leading the hospital to look at other successful models to see what could be retrofitted to Carolinas' and Anson County's population needs, Henderson said. Carolinas also conducted community outreach during the building process for its PCMH as well as involved voices from non-clinician and construction backgrounds, he told H&HN.

"Having everything in one building allows us to really build a team, not only a team in our medical home but a team with the ER [emergency room]," Medical Director Emily Cooper, M.D., told H&HN. With ER staff in the same room, Cooper said, she and other hospital leaders do not find themselves in situations in which they must determine where to send a "borderline" patient to the ER without ER staff input.

The new environment has not been without hurdles, Cooper said, but the involvement of staff from multiple spheres made collaboration on these issues far easier. An increase in medical home usage, from 19 percent to 30 percent, is one of the hospital's 2015 goals. Part of the hospital's strategy to achieve this, Henderson said, is making an effort to redirect chronically ill ER patients who would be better served in the PCMH setting.

"The other component is outside of the four walls, those patients who are in the community that need … a primary care physician, so we have other strategies with our outreach team, such as community health days, health fairs, wellness visits within the community," he said. While the provider's long-term goals are outcomes-based, he added, its primary focus is changing the patient population's behaviors and improving care access.

Population health management is a top priority for healthcare leaders in general in 2015, FierceHealthcare previously reported, particularly as healthcare increasingly moves toward a value-based care system rather than a fee-for-service model.

To learn more:
- watch the interview

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