Increasingly, the leading patient care organizations in healthcare are making an important connection, and the primary edge now among trendsetters is a growing link between population health management and readmissions reduction work. There is a reason why healthcare providers are focusing on preventable readmissions more than ever, and are more and more using population health management analytics in order to focus on the issue.

Even as the leaders of pioneering patient care organizations are addressing the issue as one of care quality and continuity of care, the cost of preventable readmissions has pushed the issue along as a performance target for payers, providers, and government agencies alike, most urgently for providers, through a new healthcare reform-related mandate on readmissions reductions, notes Jane Metzger, principal researcher at the Waltham, Mass.-based Global Institute for Emerging Healthcare Practices at the Falls Church, Va.-based CSC.

Jane Metzger

Indeed, Metzger says, reducing avoidable readmissions has become one of the most pressing issues for hospitals as they look to become accountable care organizations (ACOs).  Hospitals, she notes, have been working on discharge rates for a long time, but the combination of improving quality metrics, and the publicly listed rates of readmissions, as well as, for the first time, high financial stakes, has brought population health management into industry-wide focus. Population health management strategies can be applied to a broad range of issues, but Metzger says preventable readmissions are at the “front and center” of such work.

That importance is evident through various government mandates. The Centers for Medicaid and Medicare Services (CMS) and the Obama administration have targeted preventable readmissions as a way to reduce Medicare costs through the mandatory readmissions reduction program. There are other programs with readmissions requirements as well. “Readmissions pops up everywhere in the payment reforms for Medicare,” says Metzger, adding the emphasis has even gone beyond the federal level. “It’s not just federal payers paying attention to this,” she says. “State Medicaid programs are paying attention to readmissions, as are private payers.”

Population Health Management in Practice
Industry-leading organizations like the Minneapolis-based Allina Health System are certainly paying attention. The 11-hospital, multiple-medical-clinic organization has implemented population health management and aimed to reduce readmissions, as well as improve overall clinical outcomes through internally developed metrics. Mary Jo Morrison, Allina’s vice president of performance resources, says Allina gathered 400 disparate clinical measures, thanks in great part to its relationship with EMR vendor Epic Systems Corporation (Verona, Wis.) which could cause readmissions and developed a predictive statistical model based on that.

Mary Jo Morrison

“By virtue of having this clinical data, which includes things like blood pressure and creatinine test results, we’ve used the predictions to provide to caregivers [information on] those patients that may have a likelihood of being readmitted again,” Morrison says. She adds the predictive modeling is augmented with the second part of its population health management: information on the patient experience. This kind of real-time data includes specifics on particular patients that, for instance, have been frequent visitors to the emergency department (ED).

“If a patient comes into a hospital and comes in at 11 o’clock, by 1 o’clock that same day, we’re able to tell the caregivers that this patient has been in the ED multiple times over the past year,” she says. “That’s incredibly important, because as a care team looking at how to best support the patient inside the organization and on the outside, they can better support the patient with social work care-managers with that information.”

Allina is not the only healthcare organization employing population health management analytics to reduce readmissions. James L. Holly, M.D., CEO of the Beaumont-based Southeast Texas Medical Associates (SETMA), says his organization has been on the road to population health management for quite a while. He and his fellow SETMA physicians use various data sets and statistical analyses to audit their entire patient population and achieve continuity of care.

James Holly

“Everyone counts or no one counts. That should be the mantra of healthcare in America, and really that is the foundation behind population health management. Everyone—that’s population management; no one—that’s individuals,” Dr. Holly says. “Either everyone deserves healthcare or no one deserves it.” Thanks to SETMA’s work in population health management, and its written plan treatment for when a patient is discharged, the organization’s preventable readmission rate has improved 22 percent. Holly expects that number to improve even more in the coming year.

Moving Ahead
The future of this movement and the next plateau, Metzger says, will rely on the implementation of health information exchanges (HIEs) to help close what she calls the “preventable readmissions loop.” This means determining whether or not a patient, for instance, has received the prescribed medication at the time of discharge. Unsurprisingly, she says hospitals with successful population health management programs will have to create a tight communicative bond with the local community of physicians.

Of course, growth will come not just from an internal commitment, but from government support as well. Morrison says Allina has gotten support from federal, state, and local government agencies, and cites both external and internal motivations as critical drivers. However, in terms of the most important aspect to a successful implementation, she stresses organizations must take a multi-dimensional approach to analytics, have both retrospective and prospective analysis, and build a strong collaboration between stakeholders.