Population health relies on provider collaboration, nurse coordinators, data sharing
A day in the life of a population care coordinator shows he or she is involved in pre-visit planning; team meetings in the beginning of the morning session and the afternoon session; active outreach for care gaps (for example, reaching out to people who need mammography or cancer screenings); managing patients with chronic conditions and developing, executing and updating care plans.
FHP: What type of information does Horizon share with its provider partners to help them manage their high-risk patient population?
Peskin: We provide monthly reports to practices across a secure site. Those reports have information for practices on things like emerging ambulatory systems, emergency room visits, admissions and readmissions. They also detect rising risk of patients. We work in the total cost of care so providers can see where the costs are for a large number of categorizations. You might actually want to see that going up rather than going down because we know that patients with chronic conditions often times have comorbid behavioral health. So addressing those can have an ultimate impact on improving outcomes and reducing complications.
FHP: Have you been able to lower costs or improve quality with your population health management program?
Peskin: Based on a review of 2013 claims data comparing more than 200,000 Horizon members, we found a 14 percent higher rate in improved diabetes control, 12 percent higher rate in cholesterol management and an 8 percent higher rate in breast cancer screenings. The data also showed a 4 percent lower rate in emergency room visits, a 4 percent lower cost of care for diabetic patients, a 4 percent lower total cost of care and a 2 percent lower rate in hospital admissions.
FHP: Have there been any steps that you've put in place that didn't work?
Peskin: Certainly there are situations where we will attempt to persuade, recommend or suggest that a particular practice look at a certain process for addressing patient engagement that didn't really work with that practice. So there are a lot of what we call "special cause" as opposed to "common cause" variation. At a systematic level, we've been very good at testing things. Everything that we do and put in place we've tested in the real world before we release it. It's like releasing software. You have people who are trying to crash the software on purpose and get it to not work. So you know when you release software that it's stable. So that's how we've implemented different kind of interventions for our practices.