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At Dignity Health, A Data-Driven Population Health Strategy is Yielding Promising Results

January 23, 2018
by Heather Landi
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Headquartered in San Francisco, Dignity Health is a large integrated health system operating 39 hospitals, with facilities predominantly in California, Arizona and Nevada. Dignity Health’s network of providers comprises about 1,400 physicians that are either employed by the health system or in its foundation practice models, and an additional 6,000 independent physicians that are aligned with the health system through eight regional clinically integrated networks.

In the past few years, Dignity Health executive leaders have made significant strides toward evolving the organization from a hospital to a care continuum company and a clinically driven enterprise, and physician integration and population health management both play critical roles in this journey. The health system also has increased its focus on new models for healthcare delivery with the aim of improving patient care, quality and lowering costs in its communities.

However, Dignity Health executive leaders faced the challenge of having a fragmented approach to population health across the health system's expansive footprint, which includes eight regional clinically integrated networks, according to Julie Bietsch, Dignity Health’s vice president of population health management. “We divide our market into eight geographic regions, and each region is doing something different. We needed to get agreement from everybody on how we were going to assess the members, what care plans are going to be offered, and then how are we going to measure success. Also, before we implemented a population health technology solution, we were doing care plans on paper, and you can’t do any data analytics when you have paper.”

What’s more, risk stratification was a significant hurdle. “When you look at a population, you need to be able to say who needs wellness intervention, who is a rising risk, and who needs complex interventions. We really had one market that was doing risk stratification, and they were doing it manually,” she says.

She continues, “We also had struggled in each market to declare who is going to be the owner of risk. Now that we have identified every risk member, then who owns this to make sure we’re successful? It’s difficult to get a view on how you are doing from a system perspective because of those fragmentations.”

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Health system executive leaders were looking to make large-scale population health management a reality, and began working with Boston-based health IT company athenahealth two years ago to implement its population health management solution.

As part of its robust population health management strategy, Dignity Health wanted to develop an integrated care management platform to help implement standardized care models across its clinically integrated networks, says Bietsch, who has worked at Dignity for three years and partners with the vice president of physician integration to develop population health strategies in all the health system’s markets.

Currently, there are about 1.1 million patients cared for under value-based payment models, according to Bietsch. “Those value-based contracts range anywhere from something as simple as a network design to all the way up the cost continuum to full risk. So, about three-fourths of those 1.1 million members have up and down side risk.”

For the past two years, Bietsch and her team have been focused on building what she calls a strong foundation for the clinically integrated networks.

“We also recognized that we had a problem with out-of-network utilization, once we started looking at the data, and we needed a system to manage our out-of-network information. That’s what we’ve been focusing on for three years—those care plans, analytics, out-of-network management,” Bietsch says. “I see us evolving into things more like looking at tools and solutions around patient engagement opportunities, but right now we need to be strong in the basics.”

Dignity’s Data-Driven Population Health Strategy

Dignity Health’s population health strategy is focused on network development, implementation of payer risk contracts, alignment of clinical solutions and analytics and technology to support the integrated solution. Leveraging the platform, Dignity Health rapidly integrated a wide range of disparate electronic health records (EHRs) and aggregate data from a variety of sources, including hospital data, payer claims, lab results and prescriptions, Bietsch says.

In addition to the above data sources, Bietsch and her team recognized that admission, discharge and transfers (ADT) data was a pertinent piece of the puzzle as well. The platform now includes patient ADT data from all of Dignity Health’s hospitals, and project leaders also worked with state health information exchange (HIE) organizations and competing health systems to integrate ADT data. “We now have 13 hospital systems and two states HIEs that are giving us ADT data,” she says.

Integrating the population health platform with EHR systems was another significant hurdle. “The physicians who are employed by Dignity or are in our foundation are on two EHRs right now. By the end of 2019, we will be on one EHR. We are mapping that EHR data into the platform; we’re not quite there yet,” Bietsch says. “Part of the problem with EHR data is there are things where it’s reportable because data are in certain fields and then there are a lot of things that are just in physician notes. We’re working on things like natural language processing to extract the physician notes.”

What’s more, across its entire enterprise, Dignity Health’s IT leaders are contending with 150 different EHRs. “Every instance of EHR can be different, or every office could be putting information into a different spot, so I don’t think we’ll ever get to a point where we integrate fully with EHRs. We’re hoping that we’ll be able to integrate fully with HIEs, who will integrate with EHRs,” Bietsch says.

Dignity Health then focused on using the platform to stratify populations using the Milliman Advanced Risk Adjusters (MARA) to identify which patients are most likely to use health resources, such as patients with multiple co-morbidities. Patients can then be enrolled in care coordination programs and providers can create a care plan identifying specific patient actions that will improve the management of their disease. And, the platform enables Dignity health leaders to standardize care management workflows.

“We have built care plan solutions and we have incorporated clinical pathways for our members. So, if you have a member who is a diabetic, we help physicians with the most recent evidence-based information on how to take care of that diabetic. And then we also have care plans for our care managers using an evidence-based library,” she says. “For the past six to eight months, we’ve been pulling reports out of the system, to look at where do we have opportunities to improve? And one of the things we found is that we were still using the system somewhat inconsistently among the other markets, so we’ve been working on changing that.”

She adds, “We constantly take data and continuously learn from it, and then put measures in place to improve the results.”

Health system leaders also have recognized the intersection between population health and community health, and that the alignment and coordination of the two at the health system and facility levels is a crucial factor for success in an increasingly at-risk, value-based reimbursement environment. Leveraging its population health management platform, Dignity Health can now identify common diseases by geographic market and implement community-based programs, and this data-driven effort has yielded results, Bietsch says.

“I have one market that has a high congestive heart failure (CHF) rate, and we put a CHF clinic into that market. We’ve seen the readmission rate drop substantially, from high double digits to low single digits. We have another market with a COPD (chronic obstructive pulmonary disease) problem and we put a clinic in place. We’ve since dropped that readmission rate from high double digits closer to a one percent readmission rate. The data has helped us to look at where we need to engage and how we need to engage,” she says.

“One thing we’ve learned is that if you don’t work with the community providers, work where the patients are, and bring them into the care plan, you’re going to have a fragmented approach,” she says.

Along with improved clinical outcomes, Dignity Health also has benefitted from reduced out-of-network migration. “In one primary care physician group, the out-of-network rate was about 55 percent and now it’s down to 15 percent,” she says.

Bietsch and other executive leaders have learned some important lessons during this ongoing population health journey.

“You have to engage physicians early,” she notes, adding, “This has to be a physician-ran solution; this cannot be administration telling physicians what to do. Physicians know what to do, they just need assistance to help the patients. Our population health management solution is run by physicians and, since the beginning, any of our decisions, such as clinical pathways, are defined by physicians.”

Standardizing processes and care plans also is a critical step in this work, she says. “When you’re looking at care plans, how do you measure success if you have a lot of variability? We put a lot of standardization in place.”

And, perhaps most importantly, health system leaders need to understand that this will be a long journey. “This is very hard to do,” Bietsch contends. “You’re not going to solve this in a year. This is going to take years of commitment. If you think about the fee-for-service system, it has been around a long time. Value-based models have been around for years but it has not been as widely accepted. I would say, find a person who understands value-based contracts, and make sure they are part of your team.”

She continues, “My background is managed care; I’ve worked for the payer system for 20 to 25 years. That’s what we did every day, try to figure out how to manage healthcare costs. Now, I work on the provider side and I can take that knowledge and work with the physicians on what works within a practice. However, I realize now there is so much complexity in the system, and patients are key to making changes. You need to figure out ways to fully engage patients as collaborative members of their care team.”

To this point, Dignity Health continues to make strides in this effort, leveraging technology to get more information into the hands of patients to enable them to better manage their own healthcare.

 


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Precision Medicine Alliance Brings Democratization of Precision Medicine

October 5, 2018
by Damon Hostin and Robert Weil, M.D., Industry Voices
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The goal is for every patient to have access to the best treatment possible, when and where they need it.

Hospitals are built on data. Most often, medical data for research pile up in silos instead of being appropriately shared to develop more innovative ways to treat patients.

At Catholic Health Initiatives and Dignity Health, we have started to think differently about the possibilities that surround the data and expertise our clinicians bring to solving our patients’ care needs.  It’s why we joined forces to create the nation’s largest precision medicine partnership.

Because of that spirit of innovation, investment and the information-sharing agreements we established under the Precision Medicine Alliance, LLC, about 12 million patients in 16 states will have access to more promising treatments based on a genetic understanding of their disease.

The alliance currently is focused on advanced diagnostic tumor profiling. However, we are preparing ourselves to provide more specific diagnostic and personalized therapies for a number of genetic and acquired conditions, including cardiovascular medicine, neonatology and pharmacogenetics.

Before the alliance was formed, access to precision medicine-based care was inconsistent to all populations, making it available primarily to the well-insured and those with the personal wealth needed to pay for the specialized tests.

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In a sense, the alliance represents the democratization of precision medicine. That’s because, for the first time, we have created a cost-efficient program that allows community-based hospitals, both large and small, to become partners with the alliance and introduce these vital programs locally.

The alliance highly complements national oncological programs at CHI and Dignity Health, which together serve more than 100,000 patients annually. Starting this fall, each oncology patient at active sites will be matched to all biomarker-appropriate therapeutics and will be screened for eligibility to enroll in a clinical trial. This makes Englewood, Colo.-based CHI and Dignity Health, which is headquartered in San Francisco, the first health systems in the nation with their own precision medicine program with reach across a national footprint. Together, the two systems have 139 hospitals and hundreds of other care sites.

The alliance couldn’t have happened soon enough amid the rapid pace of advancement in cancer treatments. Identifying new genetic markers and their effects on cancer occurrence, prognosis, and treatment options occurs at a staggering pace. Even the best-informed physicians may struggle to keep up with new treatment regimens for the most common cancers, let alone rarer forms. 

The alliance is working to accelerate change. It is switching how we view and treat oncology patients throughout our network as well as working on wellness and prevention among our higher risk populations.

By actively screening patients and learning more about how genetic makeup and some environmental factors may influence health and care, we are far better positioned to identify and intervene earlier.

We already have hundreds of thousands of patients under management in the system today—a mega-community of actionable medical information. That community is enabling CHI and Dignity Health caregivers to share—in real time—their insights and outcomes on patients with cancer.

At CHI and Dignity Health, we see our early work as a catalyst for furthering this emerging science, using next generation strategies, technologies and a strong partnership.  Our precision medicine alliance is not centered on discovering the next major genetic marker.  We view our purpose as creating a model that disseminates the benefits of precision medicine to more patients and more caregivers.  Access is equity and it is dictated by our mission.

Through the alliance, CHI and Dignity Health caregivers can more effectively identify the best drug therapies and possible clinical trials for their patients. Besides changing the way we treat some of our patients, we are also creating a repository of data to drive better clinical decision-making and treatment discoveries for generations to come.

We believe our early commitment to precision medicine through the alliance has helped set the stage for even greater and wider use of this promising methodology. With that, every patient can have access to the best treatment possible, when and where they need it.

Damon Hostin is the CEO of the Precision Medicine Alliance of Catholic Health Initiatives and Dignity Health.  Robert Weil, M.D., is senior vice president and chief medical officer of Catholic Health Initiatives and a board member of the Precision Medicine Alliance.


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On Staten Island, a Highly Innovative Program That's Redefining What’s Possible Under Medicaid

September 17, 2018
by Mark Hagland, Editor-in-Chief
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Healthcare leaders on Staten Island have been achieving exciting success in care management and population health management in their community’s Medicaid and uninsured populations

Even as one hears constant complaints and concerns about the challenges facing healthcare leaders who are attempting to help shift the U.S. healthcare system from volume to value, more and more truly encouraging stories are emerging about pioneering organizations that absolutely are moving the needle, in the present moment. One of those encouraging stories absolutely revolves around the Staten Island Performing Provider System (SI PPS), a unique organization whose leaders describe it as a “Medicaid redesign program implementation enterprise.” Under the leadership of Joseph Conte, Ph.D., CPHQ, its executive director, SIPPS has been forging a path forward around robust population health for Medicaid recipients on Staten Island, the New York City borough that is the by far the smallest in population (479,000, compared to Brooklyn, at 2.6 million in population) yet third-largest in land mass, among the city’s five boroughs.

The Staten Island Performing Provider System has been participating very successfully in the Delivery System Reform Incentive Payment (DSRIP) program under the aegis of the federal government. What is involved in New York State’s DSRIP? As NYSDRIP’s website notes, “DSRIP is the main mechanism by which New York State will implement the Medicaid Redesign Team (MRT) Waiver Amendment. DSRIP´s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25 percent over five years. Up to $6.42 billion dollars are allocated to this program with payouts based upon achieving predefined results in system transformation, clinical management and population health.” The federal Centers for Medicare and Medicaid Services (CMS) approved New York State’s Medicaid waiver requested in the amount of $8 billion over five years, in April 2014.

And SI PPS manages the care of 130,000 Medicaid recipients on Staten Island, in addition to managing the care of 50,000 uninsured Staten Islanders.

According to SIPPS leaders, “Staten Island Performing Provider System (SI PPS) is an alliance of clinical and social service providers focused on improving the quality of care and overall health for Staten Island’s Medicaid and uninsured populations, which include more than 180,000 Staten Island residents. We are co-led by Staten Island University Hospital and Richmond University Medical Center. Our network of over 70 partners includes skilled nursing facilities, behavioral health providers, home health care agencies and a wide range of community-based hospitals, clinical facilities, treatment centers, social service and community organizations, primary care physicians and medical practices across the island. SI PPS is expected to bring more than $200 million to Staten Island over 5 years if successful in transforming our care delivery system. Our mission is to engage partners and stakeholders in the planning and implementation of DSRIP as we move towards a value-based payment model for Medicaid in New York State.”

Among the goals that SI PPS leaders have set for themselves:

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> Develop an infrastructure that lays the foundation for delivery system reform by transforming the Staten Island community through investment in technology, tools, and human resources that will strengthen the ability of providers to better serve our community

> Improve health literacy and share cultural competency knowledge

> Expand access to the appropriate level of care for all patients, including reducing barriers to care

> Expand outpatient and community services including home care, ambulatory detox, behavioral health/substance abuse, and primary care to reduce avoidable hospital/emergency department use on Staten Island

> Improve coordination of care and develop an integrated network

> Improve care management and disease management for high-risk patients, including patients with chronic conditions and behavioral health diagnosis

> Improve population health by addressing social determinants of health

> Integrate technology to allow for the secure exchange of health information across the PPS

> Reduce the per person cost for providing care

> Engage the uninsured, and underutilizing/low utilizing Medicaid patients and connect them to primary care and social services

> Implement innovative and evidence-based care models throughout the care continuum

> Implement training programs and learning collaborations between PPS partners that allow for the sharing of best practices

SI PPS leaders state that “These goals are being reached by implementing 11 DSRIP Projects, identified by a Community Needs Assessment, to address primary care, mental health, substance abuse, chronic disease, long term care, social determinants of health, and population heath.”

SI PPS leaders add that “We leverage a seamless platform that gathers data from multiple sources -- claims data, core reports, department of health information and the like -- and that data is inserted directly into the electronic data warehouse. With geo-mapping, we can identify areas that are lacking in key services. In creating maps of the population, we can filter in on specific conditions, and if we hover over a specific area within a specific map, we can see three years of claims data. We can figure out utilization trends, including hospitalization, medications, etc. We can also filter by demographics, types of chronic illness, etc.” Among the data sources they are make use of include direct data feeds from partners; lead providers’ clinical data; other partners’ clinical and billing data; data from care management partners; and public data; among other sources.

In addition, the SI PPS leaders have plunged into behavioral healthcare management. They note that they are pursuing “a population-health and community wide effort that aims to build capacity across systems by leveraging and developing partnerships to provide a quality integrated health care system, effective, high quality, person-centered care that supports improved health outcomes and optimal physical and emotional well-being. BHIP priorities focus on increasing and sustaining mental health/SUD provider service capacities, assisting community members to navigate behavioral health services, providing support to individuals and providers through education and technical assistance, addressing co-morbidities and co-occurring disorders, and reducing stigma and raising awareness about behavioral health wellness.” Among the numerous individual programs encompassed by the Behavioral Health Infrastructure Program (BHIP) are programs to expand the capacity of professionally certified peer workers in addiction and mental health, to help tackle the substance abuse program; the engagement of patients in the Emergency Department with substance use issues by clinicians and certified Peers to expedite linkages to behavioral health providers and reduce preventable ED visits; an innovative pre-arraignment diversion program designed to redirect low-level drug offenders to community-based health services instead of jail and prosecution; and numerous other programs.

Recently, Dr. Conte spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding the progress being made at SI PPS, and the implications of his team’s work for transformation across the U.S. healthcare system. Below are excerpts from that interview.

Can you explain the basic funding mechanism or model that is supporting your organization?

The New York State Department of Health negotiated a waiver with CMS, and received $7.2 billion over five years to fund the program. About 50 percent of that was guaranteed for pay-for-reporting and program implementation, and 50 percent was set up as pay for performance, so it is very much a pay for performance program. There are 6 million people on Medicaid, and the state spends $65 billion a year, and the federal government pays for half of that; that’s why it’s very much in their interest to fund population health; it pays dividends to everyone.

To take care of the entire Medicaid population on Staten Island?

It’s interesting. We do not pay claims or intervene on behalf of providers, with managed care companies. Our sole purpose is to create innovation and reach population health milestones with providers in the community. So the hospitals, nursing homes, FQHCs, physicians, continue in their payment systems. We exist solely to create innovation and to incent innovation. It’s very much a pay for performance program.

Tell me about some of the main programs that you and your colleagues have been involved in, around this work?

The main initiatives relate to creating integrative care models where we bring in behavioral health providers to work with medical providers and medical providers who work in behavioral health organizations, so people don’t have to shuttle around to access care. We’ve done a great deal in the prevention of avoidable use of EDs for medical and behavioral care; that’s down over 60 percent in the past three years. And a lot of that has to do with looking at data form multiple sources and identifying where initiatives should be implemented. So we have a very big focus on asthma and a very big focus on diabetes. And a lot of the work involves engaging patients with peer educators who suffer from these conditions themselves.

One of the biggest innovations has been doing this with people who have alcohol and substance abuse disorders. We have peers in the EDs 24/7; and the number of people who have engaged in treatment services has tripled in the past few years. We’ve paid the salaries for these individuals, we’ve paid their training, have paid them to go get certified; and as they’ve become certified, they’ve become hired by the organizations, because their services are actually billable. So it helps the individual, helps the patient care organizations, helps the community. And it all comes out of high-level data analytics, doing hot-spotting, geo-mapping, bringing in social determinant of health factors, looking at housing, crime statistics, poverty, graduation lists, things like that. So we’ve done things very fundamental to services, to healthcare services, but in a very smart way. The workforce transformation is also very important; we spend a lot of time and training preparing people for new roles.

What have your biggest lessons been learned so far?

I would say it is that the kind of collaboration that it takes to create transformation is something that people really want to do; but they need organizations like ours that can bring these high-level analytics and resources together. And that includes training to give people new education; as well as providing to organizations high-level opportunities to identify patients most in need. You know, you can hunt for ducks with a shotgun, but it’s not a good idea when you’re trying to conserve ammunition, right? So we’ve helped people put a fine aim on things that need to be worked on, and the community coalitions are very powerful; you can’t go it alone, so working with local governmental units is very important. Also, bringing in information form as many sources of information as possible essential. We bring in ambulance data, social determinants of health data, school data, community data; all are essential.

Have you done geo-mapping or hot-spotting? How did you figure out how to obtain those various types of data?

When we started up, we were a complete start-up; so we didn’t have any legacy systems. So we hired very bright IT people and analysts, and brought the right tools to bear so that we could really be focused on how the resources were applied; that was our core investment.

What advice would you offer the senior healthcare IT leaders in patient care organizations, including the CIOs, CMIOs, CQOs, chief data officers, etc., in terms of what they should think about around all of this?

I would tell them that turning data into business intelligence is critical, and that’s true with respect to everybody. For the medical people, it’s medical business intelligence; for the finance people, it’s financial business intelligence. Don’t get overwhelmed with data; use it to create good information for clinical and business practices, and that will allow you allow you to be successful.

What will happen in the next couple of years?

There are about 13 states that have Medicaid redesign waivers in place now; CA and TX have received extensions, and we’re hoping for an extension. We’re also looking for other opportunities to extend our work; we’ve set up an ACO. We’ve set up a form of consultancy as well.

Where do you hope to go in terms of accomplishments in the next few years?

The important thing is for us to do things that are sustainable in the community whether we continue on or not, and that’s a lot of the work we have done—it is to grow capacity in organizations in the community. And that’s why the workforce work is so important. When people have new skills and training and ability to bring change into their organizations, these certainly are sustainability factors that are important.

Is there anything you’d like to add?

I would say one thing that we’re spending much more time on now, is continuing to try to work in the behavioral health space, because especially in the Medicaid population, any number of people have co-occurring conditions—they have medical and behavioral problems. And these are the patients with the most problems and who need the most services. So giving them access to more services is important, but also being able to be more predictive about when they’ll need those services, so we can be smarter about it; that is really important.

 

 

 

 


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Cardiovascular care stands to be nothing less than transformed by the potent technologies emerging now and in the near-term future—ushering in changes to not only how readily and effectively we can diagnose and treat illness, but also in how accurately we can predict and even stave it off. From measurably more productive workflows to palpably more precise assessments, technology surely has much in store for us. Artificial intelligence, seamless data integration, remote image access, and other advances are, quite simply, game changers in cardiology, with cardiologists, their patients, and the healthcare system standing to benefit.

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