For One North Carolina ACO, a Social Determinants-Driven Strategy is Reaping Results | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

For One North Carolina ACO, a Social Determinants-Driven Strategy is Reaping Results

May 4, 2018
by Heather Landi
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The social determinants of health have quickly become the new focus in population health, with health systems and health plans showing increasing interest in the role social determinants play in health outcomes, especially with the rising burden of chronic care and the shift toward providers and payers taking on more risk.

The leaders of one North Carolina accountable care organization (ACO) give more than just lip service to the concept of social determinants, as the organization’s population health strategy centers on a community-based model for addressing social determinants of health by aligning appropriate community resources around its highest risk patients. Mission Health Partners (MHP), a clinically integrated network and Medicare ACO, has seen success through these efforts, as care managers are better able to identify the most vulnerable patients and provide those patients with a support system.

Formed in 2015 and affiliated with the Asheville, North Carolina-based Mission Health healthcare system, MHP is a physician-led ACO with a network of eight hospitals, 1,100 physicians and 90,000 covered lives across 18 counties in western North Carolina, or about 10 percent of the region’s population. The ACO's hospital network includes six Mission Health hospitals as well as Murphy Medical Center, part of the Erlanger Health System, and Pardee Hospital. The second largest ACO in North Carolina, MHP participates in the Centers for Medicare and Medicaid Services’ (CMS) Medicare Shared Savings Program (MSSP) ACO program, covering approximately 58,000 Medicare beneficiaries. MHP also covers 18,000 lives through the Mission Health employee benefits plan and about 8,500 patients attributed through Humana Medicare Advantage. In 2017, MHP added 4,700 United Medicare Advantage member and 1,500 Healthy State beneficiaries, through both Medicare Advantage and direct to employer offerings.

MHP leaders have found that the ACO’s unique care coordination approach—focusing on the social and environmental factors impacting patients’ health—has proven successful. In late October, CMS released data on the 2016 quality and financial performance results for Medicare ACOs, and that data indicated MHP achieved a quality score of 97.6 percent, up from 95 percent the previous year, and realized $11 million worth of cost savings, despite having one of the lowest spending benchmarks in the nation, according to MHP leaders.

“I think what makes us unique is that we are a very heavily social determinants-driven ACO, in that we compile social determinants data for predictive analytics, and then use that to drive our care management operations,” Robert Fields, M.D., Mission Health Partners’ medical director, says.


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According to Fields, MHP puts an emphasis on identifying social barriers to better health, and has developed a network of community partners and non-profit organizations and a process for referrals and tracking that streamlines the limited resources available to meet these members’ needs. By working with community organizations such as local food banks, the local YMCA, legal aid and substance abuse organizations, MHP connects patients with resources to address the underlying causes of members’ health problems.

“We enable community partners to engage in the members’ care plan in the same way that typically only medical providers would engage in the care plan. We hold our team accountable for closing those social determinants gaps, with the idea that if we help patients meet their most critical basic needs, then the healthcare pieces will fall into place,” Fields says. “We feel that we have proven that through the success of our value-based contracts.”

As a primary care physician, Fields says he has witnessed firsthand the impact of social and environmental factors on patients’ health, and the need for healthcare organizations to address these gaps. “My biggest frustration as a provider at the front line is that I would write prescriptions for hypertension or diabetes, knowing there was a reasonable chance that the patient couldn’t afford it, or didn’t know how to take it effectively,” he says.

He continues, “My experience would tell me that those barriers are social determinants-driven, and so when we started doing this work, it seemed clear to me that it’s honestly ridiculous to talk about patients managing diabetes if that patient has zero control over their ability to access food or their ability to get to a pharmacy to a grocery store, or to talk about someone’s COPD [chronic obstructive pulmonary disease] when the house they are renting is infested with mold; it’s about the expectations we place on people when their lives are that chaotic. It seems to me that if we’re going to manage the population we have to think enough upstream to solve those basic needs first before we can even talk about the healthcare pieces.”

Leveraging health IT tools and data analytics has been key to this effort, Fields says, as it enables data to be aggregated from multiple, disparate sources. The organization worked with health IT vendor athenahealth to drive improvements in its population health strategy.

 “A big challenge was to find a care management tool that supports social determinants,” Field says. “We were able to work with athenahealth to build that tool, and that has been the biggest value—operationalizing this social determinants model to create a community care plan.”

Historically, the only way to gather social determinants data is through nurse care managers performing member assessments. “This involves having fairly intense conversations with patients and hoping they will share intimate details about their lives with a nurse care manager, and they often do, but it takes a long time, because it takes a level of relationship and trust,” Field says. He stresses that building relationships with patients is the backbone of the organization’s care coordination approach, and while assessments continue to be an important step in the process, the use of technology has improved care coordinators’ ability to close gaps in care.

“We feel pretty strongly that any way we have of automating the collection of social determinants of health data for a significant portion of our population and then using that in a codified way to predict when an intervention is needed, is the right way to go. So rather than having to collect it by purely assessment, we can automate the process and make our clinical operations much more efficient,” he says.

As a result of the care coordination technology platform, care managers can see a visualization of social determinants gaps in the same hierarchy as clinical gaps. “A typical care plan might have heart failure, hypertension, diabetes, condition-focused care plans, but, in that same hierarchy, we’ll also see housing or transportation or food insecurity within the care plan as an equal need,” Field explains.

Community partner organizations also can log-in to the digital care management tool, view referrals sent from the care managers, conduct outreach to the patients and then report the closing of those gaps in the same tool. “We can track how many of those social determinant pathways we were able to close, and that helps us in a number of ways,” Field says. “One is to look at the productivity of our care managers, but it also helps us to identify community needs for housing or food insecurity for the purposes of advocacy and policy.”

The use of the technology tool also frees up MHP staff to focus on higher priority duties and to deliver better quality care, organization leaders say. What’s more, Field says the combination of the community approach model and the technology tools enables care managers to have a 360-degree view of the patient and better insight into the overall picture of the patients’ lives.

Mission Health Partners also utilizes athenahealth’s outreach manager tool which enables automated outreach campaigns, and that has increased efficiency in reaching patients for Medicare Annual Wellness Screenings, cancer screenings, fall risk prevention programs and other preventive care, Field says. Those programs now average a 40 percent schedule rate. The organization also utilizes athenaWell, a patient engagement smartphone app to gather patient-reported data. Patients who use the app can receive reminders of tasks in self-care, input blood glucose levels, and record their daily diets and exercise. That patient-reported data is then converted into a graph so that both patients and care coordinators can track their progress.

Beyond utilizing technology platforms to just collect data on patients, Field and his team at Mission Health Partners are focused on harnessing the data to drive timely interventions and behavioral change at the individual patient level.

“One of the things we are most excited about is that we have partnered with an analytics vendor that has created, using artificial intelligence, a predictive model for predicting who of our 90,000 patients will end up in the hospital in the next 30-days, based on social determinants data that is either publicly available or that they have purchased, so anything from credit scores, bankruptcy rates, etc.,” Field says, noting that the predictive analytics model utilizes social determinants and claims data. “That’s been a new path of analytics that we have embarked on, and that will help us prioritize our patients that we perform outreach on to an even greater degree.”

What’s more, MHP leaders are interested in leveraging patient engagement tools to drive behavioral change in patients. “How do we get patients from point A to point B, based on their ability to self-manage and how do we motivate that? How do we give appropriate feedback to patients when they are doing the right things, or the ‘wrong’ things?”

Field continues, “And, then, if we can figure out how to affect behavior change appropriately, how might we actually design health plan benefits around a patient’s behavior change? If a patient is doing what they need to do to manage their conditions, can that positively affect their premiums as an added motivator? I’m interested in how the work that we’re doing translates into benefit design.”

The harnessing and leveraging of data will continue to be a big area of focus for the organization, Field says, including the ongoing integration of social determinants predictive analytics into care coordination tools and the integration of clinical data from across the provider network.

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NCQA Moves Into the Population Health Sphere With Two New Programs

December 10, 2018
by Mark Hagland, Editor-in-Chief
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The NCQA announced on Monday that it was expanding its reach to encompass the measurement of population health management programs

The NCQA (National Committee for Quality Assurance), the Washington, D.C.-based not-for-profit organization best known for its managed health plan quality measurement work, announced on Dec. 10 that it was expanding its reach to encompass the population health movement, through two new programs. In a press release released on Monday afternoon, the NCQA announced that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.”

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” said Margaret E. O’Kane, NCQA’s president, in a statement in the press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs. The program evaluates organizations in: data integration; population assessment; population segmentation; targeted interventions; practitioner support; measurement and quality improvement.”

Further, the press release notes that organizations that apply for accreditation can “improve person-centered care… improve operational efficiency… support contracting needs… [and] provide added value.”

Meanwhile, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. The program evaluates solutions on up to four areas: data integration; population assessment; segmentation; case management systems.”



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At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
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The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.


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We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.



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