The Patient-Centered Primary Care Collaborative’s (PCPCC) new report “Managing Populations, Maximizing Technology: Population Health Management in the Medical Neighborhood” was co-authored by Marci Nielsen PhD, PCPCC CEO and Michelle Shaljian, PCPCC’s Director of Public Affairs. PCPCC is working to build a strong foundation for primary care and the Patient-Centered Medical Home (PCMH).
The report discusses how practices deal with very different populations and needs within communities. For example, a case study focusing on the Bon Secours Virginia Medical Group located in Richmond Virginia, examines how they effectively use technology to manage their accountable care organization model.
Bon Secours a multi-specialty group practice with 140 locations treating 25,000 patients in the state, started a medical home initiative called the “Advanced Medical Home” pilot in June 2010. Since that time, eleven practices have earned NCQA recognition as patient-centered medical homes. The program’s objective is to make it possible for care teams to double the size of their patient panel without overburdening themselves or sacrificing quality of care.
Bon Secours has been embedding care managers or nurse navigators into the primary care team. The nurse navigators are RNs who are either board-certified case managers or actively working towards certification. Each nurse navigator is assigned a panel of about 150 high-risk patients where the nurses develop a personal relationship with the patients usually by phone but also in person.
Bon Secours realizes that the role of health IT has a big impact. As a first step, the medical group implemented an EHR into each practice operating within their system. They built a registry to identify high-risk and high-utilization patients based on the number of medications taken and the number of visits made to the emergency department.
The data obtained encouraged Bon Secours to develop a more robust scalable registry to examine population health workflows in their practices and enable analytics and predictive modeling across multiple clinical conditions.
After integrating the EHR system with a population health management platform, the organization was able to aggregate all source data into a population-wide registry to enable multiple quality improvement programs to be implemented simultaneously. The registry stratifies the population by risk while enabling each care team to drill down to the data they need about cohorts and individual patients.
One of the priorities is to prevent 30-day readmissions. The medical group now uses an automated outreach system to identify discharged patients, link them to a primary care provider, and then pinpoint patients at high risk for readmission.
Flagged patients are called within 24-72 hours to reinforce discharge instructions, to make sure that their medications are reconciled and let them know that an appointment needs to be scheduled with the primary care team within 5-10 days after discharge.
Go to www.integration.samhsa.gov/news/PCPCC_Population_Health_FINAL_e-version.pdf to view the report.