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The 2015 Healthcare Informatics Innovator Awards: Third Place Winner—Bon Secours Medical Group

March 17, 2015
by Gabriel Perna
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Navigating the bumpy roads of population health

To know where Bon Secours Medical Group (BSMG), a growing multispecialty organization that includes more than 600 Richmond, Va.-area physicians, is going on its journey to value-based, population health management, you have to know where Thomas Auer, M.D. and Robert Fortini, R.N. have been.

Dr. Auer, the CEO of BSMG and Fortini, the group’s chief clinical officer, came to the organization in 2009 from the Queens Long Island Medical Group. They went from a heavily capitated environment to nearly 100 percent fee-for-service. The goal was to build value-based patient-centered medical homes (PCMH) and introduce the concept of team-based care to “our fiercely independent practitioners,” according to Fortini.

Under the guidance of Auer, Fortini and other leaders at BSMG, they’ve come a long way in a few years. Certainly, there is a ways to go, but as Fortini says, “We’ve moved the dial a bit.” In total, 27 BSMG sites have achieved PCMH recognition by the National Committee for Quality Assurance (NCQA), and seven are in the midst of applying. Furthermore, the organization has accountable care organization (ACO) contracts with many of its commercial payers and was recently accepted as a Medicare Shared Savings Program.

Thomas Auer, M.D.

The medical group has created a PCMH environment where advanced information systems are gathering data from different sets of clinical and payer data to provide preventive care for high-risk patients. Technology alone though is not enough to create change. BMSG has invested in employing dozens of nurse navigators, who work at large and at individual practices and help to appropriately navigate the care for specific high-risk patients.

“We’re very dedicated to population health and the transition to a different view on, how, particularly, primary care and then specialty care, is used and interacted with the community,” Dr. Auer says. “It all starts with advanced patient-centered medical home. Finding the patients that we’re not seeing and getting them in for care. It’s easy to take care of what we see. It’s not as easy to take care of the patients we don’t see. It’s an aggressive outreach philosophy to find the patients we are seeing and not seeing and take care of them appropriately. It sounds easy, it’s not at all.”

The depth of BSMG’s work to make the difficulties seem easy is why the organization stands out in a field of pretenders. Like everywhere else, the challenges of changing the culture and properly evaluating performance metrics exist at BMSG. Yet, not everyone can say they’ve invested as much resources, time, and energy as they have.

Layering Pop Health Capabilities on Top of the EMR

From a technological perspective, everything begins with the organization’s Epic (Verona, Wisc.) electronic medical record (EMR) system. Both the inpatient and ambulatory sides of the organization are on the platform. This allows for a “longitudinal perspective,” according to Fortini. “Knowing what happens with a patient from the hospital to the home is great,” he says.

Robert Fortini, R.N.

Built on top of that EMR, BSMG has implemented population health capabilities to mine high-risk registries (35 in all) as well as multiple streams of payer data and various diagnosis codes (a capability from the Dallas-based Phytel) that ultimately helps stratify risk. The different sets of data can identify the risk category of a patient or the gaps in preventative care that another patient may have. The software has the ability to push a message to the provider when a patient is in need of a service.

“The scalability of that [technology] is really powerful and something we couldn’t afford to do in man hours,” Fortini says. “It’s really important to leverage that technology to essentially capture the at-risk segments of the population.”

Once this is done, the communication element comes into play. The nurse navigators then call then patient and with a few simple questions, identify the risk for readmission or worsening of illness. However, this doesn’t always work. That’s where MyChart, the patient portal built within its Epic EMR, is a benefit. According to Auer, one-third of patients communicate with them through it. The tool allows patients to book appointments, renew prescription orders, or communicate securely with a provider if they have a question on something.

Joyce Rusincovitch, R.N., nurse navigator for an internal medicine physician practice at BSMG, says it can prove to be a vital form of communication between the two parties. Patient reminders through this platform can save on outreach calls.

“We can send messages to them if they we are having a hard time reaching someone through the phone, you know a lot of people are on the phone all day. We can just send them a MyChart message and let them know what we are trying to get a hold of them for,” Rusincovitch says. “The younger population really appreciates that.”

Not only can the nurse navigators, and other members of the care team, communicate with the patients through electronic means;  they can also talk with each other. Rusincovitch and Angel Daniels, R.N. the clinical manager PCMH at Bon Secours, say this coordinates care, much faster in real time and more effectively.

Care-Traffic Controllers

Giving the nurse navigators this kind of capability is important, because as Fortini says, they are the “care-traffic controllers.” As he tells it, there are two different kinds of navigators. Administrative managers, like Daniels, who are directing data and embedded navigators to the right place. Then there are embedded navigators, like Rusincovitch, who are in the weeds, acting upon that data directly with patient. Both sides are proof that the intersection of people and technology is the lifeblood of Bon Secours’ Medical Group’s advanced patient-centered medical homes.

Angel Daniels, R.N.

The value of nurses in this role is certainly not lost on Fortini, Rusincovitch, Daniels, or anyone who understands how with their background, they can turn a complex care environment into a cohesive unit.   “Nurses have the clinical background and understanding of many of these processes, we’re dealing with them every day with our patients. We’re used to being educators and looking at the patient as a whole and finding the barriers to their care. We’re able to identify those social issues, the mental health issues, and a wide a range of things that allow them to be greatly involved with the management of care,” Daniels says.

The other value nurses bring is relief. Doctors do not have the time to focus on those social and preventative care efforts as intently as they’d probably like. In the ideal setting, the nurse navigator and doctor work hand-in-hand to seamlessly provide preventative care for the high-risk and fill in the gaps. That’s how it is for Rusincovitch, who says she is spoiled by the relationship she has with her doctors.

Cowboys vs. Pit Crews

Building this kind of relationship takes time. Auer and Fortini note that most doctors had no idea what to do with their embedded nurse navigators three years ago. Not only that but it was a brand new role in the organization that had to be created from the ground up. It took doctors a while to understand that the navigators weren’t there to provide wound care. Now, in most places, Auer says if he pulled a navigator, he would get a wave of complaints from the doctor.

Despite this, Fortini still cites the cultural aspect of getting doctors to overcome their independent mindset and embrace a team-based environment as one of BSMG’s biggest challenges. He calls it the problem of “cowboys vs. pit crews.” “Doctors are traditionally lone rangers. They were trained that the buck stops with them,” he says. “To make an ACO work, you need to play ball.”

Another challenge is measuring outcomes, says Fortini, who notes that if he is going to be paid on performance, his performance has to accurately affect the outcome. The data is currently fraught with wrenches and outliers, which prevents this from being totally possible. He uses readmission rates as an example. “If a patient is discharged to a hospital to a rehab facility, which in some payer systems still shows up as hospital care, they’re being readmitted. That shouldn’t count as a 30-day readmission and in some cases, it does,” he says.

Despite these challenges, BSMG has been able to achieve the all-too-important return on investment (ROI) for both technical and human resources while improving in several vital metrics. Yes this includes the aforementioned readmissions rate, which in the case of several payers is well below the national average. They’re also able to handle more discharged patients per month, which will keep that readmission rate down.

What’s Next

In the coming year, the advanced PCMH efforts will continue, as BSMG recently added urgent clinical care centers and retail clinics to the mix. They’re putting nurse practitioners in supermarkets. They plan to add a telemedicine element, giving 24/7 access to providers. These moves are all about total access, Auer says. He and Fortini, two veterans of value-based population health, know there will be no shortcuts on this journey.

“It’s not for the faint of heart. It’s not a straight-line activity.  It’s very bumpy and it’s very broad,” Auer says. “You have to have super quality people, you have to create champions who are believers and sellers of their new world. And you need to spread that change. It’s a critical change. It takes time. We’ve been at it five-and-a-half years and we have a long way to go. You can’t do it overnight, you can’t just do a quick NCQA application. It’s a lot of people work,” he concludes. 


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