As the U.S. continues to move into the “new” healthcare—one that puts an onus on cost effective value-based care—the question is not whether healthcare organizations should respond to the current population health management (PHM) trend, but instead how they are going to innovatively do so.
To date, population heath strategies have been mostly focused on adults, which on the surface makes sense, considering that the highest-cost and highest-utilization population is in the adult world. Certainly, population health in a pediatric environment is a new frontier in population health management that few organizations have tried to tackle, because of the enormous amount of effort it takes to customize the analytics technology and clinical protocols to address the unique needs of children, says Julie Harris, director of quality programs at the Portland, Ore.-based Children’s Health Alliance (CHA). CHA is a not-for-profit association of 100-plus independent primary care pediatricians in Oregon and southwest Washington who work together on improving quality in pediatric care through the Children’s Health Foundation, formed in 2007.
Indeed, robust systems and models for pediatric population health management have simply not been standardized, says Harris, who is also director of quality programs at the Foundation. Many health systems treat children as though they are small adults, but their needs are very different. Managing conditions such as attention deficit hyperactivity disorder, autism or multiple behavioral issues, requires different care approaches that adapt to the many developmental stages in a child’s life, she says. “Everyone recognizes that improving the health of children improves the health of adults down the road. But that’s not where volume and cost is,” Harris acknowledges. “Also, managing the most complex adult issues focuses on maybe three or four medical conditions, whereas addressing the most complex issues of children spans 10 or 15 issues,” she adds. “So the complexities are significantly higher in pediatrics, and that might also be why health IT’s population health efforts haven’t focused on this group.”
Since 2009, the Foundation’s goal has been to achieve better health outcomes by improving the understanding of child/family support needs and targeting proactive care management and coordination of medical, physical and behavioral health services for children, adolescents and their families, says Harris. “We wanted to look beyond the medical conditions of children, such as 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,” Harris says. “We also included family factors, as children are dependent on their caregivers and parents. These are necessary for proper care coordination,” she says. 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.
From L to R: Julie Harris, Albert Chaffin, M.D., Deborah Rumsey
Three Phases of Pediatric Care Management
Developing a pediatric-focused population health management framework is no small task, but it has become a pioneering achievement for the Children’s Health Alliance. Despite the challenges involved, the Foundation was determined to create its own model for pediatric population health management and implement it through educational efforts and the use of PHM technologies. In 2009, 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, Harris notes.
In 2012, the Foundation began hosting monthly pediatric care management improvement collaborative sessions in the community. The goal was to develop office-based care management competencies in pediatric practices through facilitated sharing amongst independent practices, targeted education and community engagement forums. The result of this effort was 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, Harris says. “The assessment tool enables pediatricians to identify the level of support the child/family needs in order to optimally manage his or her overall health. Within the first 20 months of this quality improvement effort, over 80,000 patients have been assessed and stratified to guide appropriate care management support and services,” Harris says.
Then, 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. They chose a solution by the Alpharetta, Ga.-based Wellcentive, with the data aggregation, care management and analytics capabilities to successfully support pediatric PHM by translating evidence-based pediatric protocols into actionable care alerts and measures that are meaningful in promoting high quality primary pediatric care –such as developmental screenings, immunizations, chronic condition management and preventive care, says Harris.
“We believed it was important to equip our providers with tools to drive a higher standard of care, and that this would help demonstrate the value of proactive pediatric care management. It would also help payers recognize the value of quality improvement innovations and measures driven from the point of care," she says. The solution integrates data from pediatricians’ electronic health records (EHRs), insurance claims and other clinical information to provide a more complete picture of their patients’ health, Harris says. CHA includes 20 different pediatric care sites operating on nine different EHR systems, so much of the interfacing is still in progress, she notes.
A Flourishing Solution
According to Albert Chaffin, M.D., pediatrician and chair of population health management at Children’s Health Alliance, and also a pediatrician at Pediatric Associates of the Northwest, the tool allows clinicians to explain what people have known along— that there are needs beyond just the medical diagnosis that aren’t verbalized or explained well to others. “In pediatrics, we have found that you have the medical diagnosis, the needs of the patient, and the needs of the family,” he says. “Most of the time, these are boundaries to improving the medical condition. We have recognized that for a long time. This tool allows us to put data into it, and be able to tackle the problem in a fashion that makes it more actionable and meaningful,” Chaffin says.
Putting it into practice, care managers can easily be overwhelmed very quickly if you just use medical diagnoses, Chaffin continues. But pediatric patients are dynamic in moving—there are various different stages of child development—and that’s why it works so well, he says. “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,” Chaffin says. “But we won’t leave it there, we will revisit it after some time. So just like pediatric patients are dynamic in moving, this is a dynamic moving tool as well.”
According to Deborah Rumsey, executive director, Children's Health Alliance, one of the driving principles of CHA is its board of 10 pediatricians, who before launching into any decision or investment, ask the questions, “What value does this bring to the patient? How does this improve quality of patient care?” As such, this tool “brings that value,” she says. "After focusing [several] quality improvement efforts on care management of children across our communities, our pediatricians have difficulty seeing the complete picture of their young patients," Rumsey says. "Because of how care is administered in silos within our fragmented U.S. healthcare system, providers often have minimal visibility into other areas of a child's care and knew that gaining a 360-degree view was critical to better outcomes.”
A key to the initiative, continues Rumsey, is to see beyond the walls of clinics in order to really care for the patient. “It’s important to understand for pediatricians to see what’s happening outside. There is accountability that is now on the primary care pediatrician, as they are expected to care for their population. Having these feeds from external sources can help them better understand and better coordinate care for patients,” she says.
Developed by Physicians
What’s more, rather than being able to rely on existing standard models or templates for managing their populations or implementing best practices, the Foundation needed to perform much of the groundwork itself, says Harris. In fact, CHA practitioners and the Foundation found that even those standard pediatrics measures that did exist in many cases weren’t detailed enough to drive specific quality improvement action, she says. “The pediatrician members of the Foundation took action by forming a task force of a dozen physician and nurse leaders across multiple independent practices to blaze new trails by developing and customizing protocols themselves, resulting in a PHM solution with high clinical value and provider engagement,” Harris says.
To this end, because the data is meaningful and actionable, providers have been on board, says Chaffin. The easiest example is with asthma care, he notes. “By using this information from the registry and the Care Management, Analytics and Reporting Tool (CMART), we were able to track their level of care over time, decrease their ER visits, and increase their medication adherence. A lot of that is driven through being able to measure ourselves against standards, see how we’re doing and create benchmarks that we all want to meet. And we have been able to meet those benchmarks over the last few years,” he says. “Physicians see that benefit and it drives them,” Chaffin adds. “Is this something that will improve the health of our patients? This is not like what we get right now from private payers. That data is claims-based, and not necessarily meaningful. None of this is easy, but we all want to improve healthcare,” he says.
Every year, CHA aims for a certain percentage of patients with asthma who have had an asthma well visit in the last 15 months. Currently, results include a 360 percent increase in development of home action plans for patients and a 230 percent increase in annual asthma well visits. What’s more, the ED visit rate among their asthma population is consistently 20 to 40 percent lower than the benchmark population, and has dropped almost 40 percent since 2010, notes Harris. With the more sophisticated technology infrastructure in place, which builds PHM and care coordination into the care team workflow, CHA leaders say they expect to generate savings in other areas as well.
The immediate value of this project is an improved care experience for children and families, better outcomes and, eventually, lower costs, notes Harris. But the long-term benefit is more striking, she says. “The fact is that healthier children become healthier adults. By proactively managing the health of children in their population, CHA and the Foundation are helping set children on a trajectory toward lifelong good health.”