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.”
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.