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In the Pacific Northwest, a Breakthrough in Population Health Management

March 19, 2015
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It is Innovators week for us at Healthcare Informatics, an exciting time when we reveal our four 2015 Innovator Award-Winning teams, as well as six runners up. The stories of these winning teams have now all been released on our website (check them out!), and undoubtedly, all of these organizations deserve to have the stories told, for their innovation is helping move the industry forward during one of its most historically challenging times.

The healthcare organization that I reported on for the Innovator Awards was the Portland, Ore.-based Children’s Health Alliance (CHA), a not-for-profit association of 100-plus independent primary care pediatricians in Oregon and southwest Washington, who have the common goal of improving quality in pediatric care through the Children’s Health Foundation, formed in 2007.

What the folks are doing at CHA around pediatric population health management (PHM)—as opposed to focusing on adults, which has been the standard when it comes to PHM—is really impressive. It all began for CHA in 2009, when the Foundation began a quality improvement program for asthma care management improvement, including the development of a pediatric asthma registry. The group has, to date, achieved 80-800 percent increases in the number of patients receiving evidence-based clinical protocols in pediatric asthma care.  Then, in 2012, the Foundation began hosting monthly pediatric care management improvement collaborative sessions in the community, an effort that resulted in the development of a methodology to risk-stratify children with chronic health conditions, informed by an assessment of medical complexity, patient functioning, and family factors. In 2014, the Foundation began implementing the successful child/family-focused pediatric care management approaches and quality measures it had developed into proactive care actions and alerts that could be supported by a population health management analytics solution from Wellcentive.

But beyond all this, when interviewing the leaders at CHA, what stuck out most to me was their passion and determination to look at more than just the medical diagnoses of their patients. Specifically, Julie Harris, director of quality programs at CHA told me, “We want to know if a child was in a wheelchair or needed feeding assistance. Those are things that wouldn’t show up in clinical diagnosis code, but affects the level of support and care coordination needed for that child and his or her health,” she says. “We also included family factors, as children are dependent on their caregivers and parents. What’s the family dynamic like? These things are necessary for proper care coordination.” Looking at all of those factors allowed pediatricians to focus on different set of criteria for assessing the needs of the families and patients, as well as what it would take to carry out care management, says Harris.

Indeed, it’s easy to get caught up in clinical diagnoses when caring for a patient, but CHA is proving that complete care requires a lot more than that, especially for children, who are dynamic in moving,  a phrased used by Albert Chaffin, M.D., pediatrician and chair of population health management at CHA. Dr. Chaffin explains that there are many different stages of child development, and during these stages, social factors can change. He says that you might have a kid who has lots of medical complexities and is being monitored well, the parents are involved and engaged, the social factors are in line, and medically he’s okay, so you can drop the support level down. Things are constantly changing.

Certainly, understanding socio-economic factors of patients helps one understand the health and well-being of population groups, as well as inequalities among and within groups. It helps achieve “health equity,” a term that the Centers for Disease Control and Prevention (CDC) defines as when everyone has the opportunity to attain their full health potential and no one is “disadvantaged from achieving this potential because of their social position or other socially determined circumstance.” Health organizations, institutions, and education programs are encouraged to look beyond behavioral factors and address underlying factors related to social determinants of health, says the CDC.  

What’s more, when talking about social determinants of health, oftentimes that recognition is coming at the health plan or Medicaid population level, but it hasn’t trickled down to physician level in terms of how they can incorporate that into their care, according to Deborah Rumsey, executive director of CHA. Rumsey told me that health plans are trying to solve it on their own, and are aware of it, but CHA’s goal is to incorporate it at the point of care. Whereas the Foundation has only now begun to correlate the factors of their assessments and measure how this segmentation results in higher quality care, it has successfully developed a system for targeting pediatric populations by risks beyond just the medical condition where no sufficient model has really existed before.  

At HIMSS15 in Chicago next month, CHA will be presenting on pediatric population health, a session which I strongly encourage people to attend. And while I’m at it, all of our Innovator-Award winning teams will be at HCI’s Awards Reception at HIMSS, at The Palmer House Hotel on April 13th. To that I say, congratulations to all of the winning teams this year for their fantastic innovation. I hope these projects serve as examples of what is possible in healthcare today.