Care Continuum – Why Population Health Has Become the New Treatment Model

“Ten years ago, we focused on the patient up until they left, and the mindset was, ‘they’re not my problem anymore,’” said the director of Transitional Care Management at Holyoke Medical Center. “Now, we’re basically responsible for that patient throughout the continuum of care. Our role does not stop at the door.”

Instead, he continued, after a patient is discharged, he or she receives a call to make sure they understand their transitional care plan, if they were able to get their medications, and if they keptn their follow-up appointment with a primary-care physician, if needed. Patients with complex diagnoses like COPD, congestive heart failure, diabetes, and depression will get serial calls every week to make sure they’re following up on their care plan.

As a result, Holyoke has maintained the lowest readmission rate in the state, Ipekdjian said. “We only anticipate this is going to get better as we progress and develop our programs.”

What he described is one aspect of population health, a broad term with many facets, but one key element: it represents a shift from the old fee-for-service model of hospital care into one in which providers across a spectrum of disciplines share responsibility for outcomes, both when patients are in the hospital and after they leave.

Healthcare professionals who work in population health talk about the ‘triple aim’ of improving the health of the population they serve, improving the experience of care, and doing both while lowering costs.

“We’ve jumped into this area very seriously,” said Dr. Evan Benjamin, chief Quality officer and senior vice president of Quality and Population Health at Baystate Medical Center. “We redesigned our entire strategic plan to get to a value-based healthcare delivery system. I think the biggest thing for us is really trying to move from what I describe as a hospital-based health system in the past to a true healthcare delivery system, where we’re integrating our providers, making care much more efficient, and improving the health of the population, but, more importantly, lowering health costs. The triple aim is a nice guiding principle for us.”

Lisa Casasanta, who accepted the role of vice president of Population Health for Mercy Medical Center and the Sisters of Providence Health System last year, is responsible for overseeing and aligning population-health strategies and their associated performance metrics.

“I’m in charge of the care continuum, which involves both inpatients and outpatients, to hopefully make patients’ care transitions smoother, as well as increase the quality of care,” she explained. “We’re really trying to follow patients from an inpatient setting to their next site of care, whether that’s home or skilled nursing or rehab or whatever. We follow that patient along the continuum so no balls are being dropped.”

The triple aim may seem contradictory, but Casasanta said achieving it is really a matter of being smart about treatment, not cutting corners.

“It’s not just a cost-saving measure. You’re also responsible for making sure patients are more satisfied as well as receiving quality care. Thirty years ago, it was easy to cut costs by just not doing things. We’re saying we want to do everything that’s needed, just in a more holistic way to trim down some inefficiencies.”

And it does work when it’s done right, she continued. “The hardest thing is, it’s a culture shift. I think people, families, are used to showing up and saying, ‘I’m here, take care of me, fix me,’ where, in population health, we’re not just trying to get patients home; our ultimate goal is to get patients back to where they started with appropriate services.”

Broader View

Jeff Harness, director of Community Health and Government Relations at Cooley Dickinson Hospital, said population health often takes a public-health approach.

“If someone keeps coming to the Emergency Department because they have an asthma flareup, the typical medical response is to diagnose it, treat them, get them over the acute respiratory distress they’re experiencing, and send them home, telling them to follow up with their primary-care doctor, which they may or may not do,” he explained.

“The public-health approach,” he continued, “says, ‘let’s take the next step and start identifying what the home conditions are. What’s the indoor air quality where they live? Maybe there’s exposure to second-hand smoke or rodents or an ancient shag carpet from the ’70s. A public-health approach says to take care of the environment, and that will take care of the asthma problem. It’s really medicine and public health working on the continuum together.”

Dr. Peter Davidson, medical director of the Cooley Dickinson Physician Hospital Organization, said health systems have come to recognize that most determinants of health aren’t restricted to what happens in the doctor’s office for 15 minutes. That’s where the concept of the patient-centered medical home comes in, a model in which primary-care physicians coordinate further care for patients.

“We develop a care plan for the patient, which is not necessarily me saying to the patient, ‘here’s what we’re going to do,’ but working with the patient to identify one or more ways in which the patient can take care of themselves,” he explained.

That means identifying barriers to care. For instance, someone with diabetes who needs to change the way he eats might not be able to afford healthy food, or might not have healthy food options nearby. “That goes more to social determinants, and in the past, a physician might say, ‘gee, I’m sorry.’ But going forward, we have to go beyond that traditional response and work collaboratively as a team,” Davidson said, to make sure patients get the resources they need to stay healthy.

On a community-wide level, Harness said his team has collaborated with a number of organizations to identify regional health issues. For instance, they noted that Easthampton has experienced higher-than-usual death rates from cancer, and cancer incidence can be exacerbated by lifestyle factors like unhealthy eating and physical inactivity. So Cooley Dickinson partnered with public schools to create school gardens and integrate healthy-food education into the curriculum, as well as establishing healthy-cooking classes in the community.

“No one program will change anything,” he said, “but when we add up all the efforts heading toward the same goals, eventually we’ll reach a higher level of impact.”

Leading Edge

Benjamin told HCN that Massachusetts has led the way in population-health trends like accountable care, where a group of multi-disciplinary providers are paid to manage the care of a patient over time, and bundled payment programs, where payment is bundled over 90 days and quality and cost of care can be tracked and improved.

“Baystate is a large, integrated delivery system with not only four hospitals, but a visiting nurses association, a large physician group, and our own health plan with Health New England,” he said, all of which provides plenty of opportunity for coordination.

For example, he went on, Baystate’s primary-care practices have moved to the patient-centered medical home model, complete with care-management resources and patient navigators to help patients, well, navigate the system. “Often, patients feel very lost when they’re referred from one provider to another. This is enormously helpful to make sure patients are in the right place, keeping their appointments.”

In addition, Benjamin said, “we’re creating care models and tools that help better engage the patient and do what I call proactive outreach. In the past, health systems were really good at taking care of patients who showed up. Now, we’re saying, ‘wow, we’re responsible for the entire population, whether they’re coming to us or not. And if they’re not coming to us, we have to find out why. We have to do better outreach. If a diabetic patient hasn’t been seen in six months, we have to contact them to see how things are going. We’re moving from reactive to proactive outreach.”

This push toward population health value-based care isn’t going away,” he said, no matter what changes Republicans make to Obamacare over the next few years. “A lot of things in the Affordable Care Act may change — funding, taxation, the coverage — but this overall concept of the bundled payment, changes like ACOs, and trying to get better population health — is clearly the future, and we feel very good about that.”

Casasanta agrees that, by following these new models, hospitals and health systems are on the right track.

“In the next 15 to 20 years, if population health is done right, hospitals across the country will have a much smaller piece of the pie, and you’re not going to need the acute-care setting as much as we currently do,” she said. “We are trying to avoid unnecessary admissions while keeping people with chronic conditions healthier. There will be more reliance on the primary-care physician, and we’ll be utilizing healthcare dollars in a different way.”

Hospital stays are already shorter than they were a few years ago, she added, which is an ironic goal, considering that admitting patients has long been the bread and butter of any health system. “But in years to come, more investment needs to be done in home care, in outpatient rehabilitation. People are still going to need services. How will we provide them?”

The answer to that question is already taking shape in hospitals across the country — and in the communities just outside their doors.