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Working in Diverse Markets, a Healthcare Company Achieves Noteworthy Population Health Results

April 21, 2017
by Mark Hagland
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Alignment Healthcare’s senior executives share their perspectives on population health management progress

The Orange, California-based Alignment Healthcare, which describes itself as “a population health management company focused on improving care delivery, one patient at a time,” is a complex, multi-faceted healthcare organization with very different books of business in different healthcare markets in the three states in which it operates—California, North Carolina and Florida. Not surprisingly, that results in complicated explanations of what it does. But whether it is operating as a health plan or a provider of care management or other services, Alignment Healthcare is making serious progress in some key areas around population health—and that is worth noting.

Altogether, the organization serves more than 50,000 people in California, North Carolina, and Florida—with 32,000 of those individuals in California, 9,000 in North Carolina, and 8,000 in Florida—and is growing at 60 percent per year.

The organization uses a statement that summarizes what its people do, and how they do it: “We lead with a proven, replicable and scalable clinical model that improves quality while decreasing costs. We are a one-stop-shop, able to bring health providers (physicians and hospitals) and payers (health plans) onto one team to improve the health and wellbeing of Medicare beneficiaries at a lower cost,” the statement says.

And, in that regard, Alignment Healthcare executives note the following gains they’ve made in the markets in which they operate. Among them:

>  In California, seniors have seen 50 percent fewer hospital admissions in 2015 than before they enrolled in Alignment Healthcare’s home-monitoring program.

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>  In North Carolina, the 30-day re-admission rate for patients enrolled in the organization’s home-monitoring program for all of 2015 was zero—compared to a national Medicare average readmission rate of about 18 percent. This is especially meaningful because these patients are the sickest of the sick.

>  In Florida, Alignment Health has achieved a 43-percent lower hospital inpatient admission rate than the Medicare fee-for-service market average.

>  Also in Florida, it has achieved a 54-percent lower hospital readmission rate than the Medicare fee-for-service market average.

>  In California, it has lowered the ED visit rate by 38 percent, among plan members enrolled in its home-monitoring program.

>  In California, plan members enrolled in the organization’s hypertension management program have seen an 8-percent drop in systolic blood pressure.

>  In North Carolina, enrollees in the organization’s diabetes management program have seen a 20-percent drop in hemoglobin a1c values.

As to how Alignment Healthcare operates, in California, it is a health plan that manages the care of more than 32,000 covered lives in California. In North Carolina and Florida, it is a risk-bearing entity that takes financial risk and management responsibilities from health insurers and manages defined populations under contract.

Recently, Arta Bakshandeh, D.O., the senior medical officer, and Kerry Matsumoto, the CIO, of Alignment Healthcare, spoke with Healthcare Informatics Editor-in-Chief Mark Hagland about the progress that they and their colleagues are making in managing defined populations through data analytics-driven care management programs. Below are excerpts from that interview.

Alignment Healthcare is a rather complex organization, isn’t it? Can you summarize how you work in the different markets in which you operate?

Arta Bakshandeh, D.O.: In California, we are a health plan, and we hold a Knox-Keene license with CMS [the federal Centers for Medicare and Medicaid Services] and hold 35,000 covered lives, where we’re the payer. In Florida and North Carolina, we’re the risk-bearing medical services organization, and we take the financial risk and management from a payer.

Is there an easy phrase that encompasses that?

Bakshandeh: Population health describes what we do. We are managing a Medicare population in almost every realm that you would manage Medicare—Medicare Advantage, as a health plan; as a partnership; under fee-for-service; and also as a delegated medical services organization. We also deliver services, when we’re not the risk-bearing entity, and contract with a health plan or health system, and help them or teach them to deliver care in Medicare Advantage, using our analytics, and we get a PMPM [per-member per-month capitated payment] and a gainshare. At the end of the day, our mission is to improve care one patient at a time, whether we’re the plan, the risk-bearing entity, or services organization.

So the term ‘population health management company’ is a term that correctly encompasses what you do?

Bakshandeh: Yes, that’s correct.

You’re in how many metro markets or regions?

Bakshandeh: Alignment Healthcare is the parent company, based in Orange. From there, we operate in three states—California, North Carolina, and Florida. We’re the health plan in California, where we’re called Alignment Health Plan, based in Orange, with more than 32,000 covered lives—in Medicare Advantage. In North Carolina, we’re called Alignment Healthcare of North Carolina, with multiple health plan partners, including Humana and FirstCarolinaCare, in Wake County. And services are in six counties, with a risk model in county. In California, we operate as Alignment Health Plan. In Florida and North Carolina, we partner with insurers and plans, and provide services under the name of Alignment Healthcare. Alignment also partners with hospitals, physician groups, and health systems, and provides services under the name of Alignment Healthcare.

How do you see population health right now, in the contexts in which you work?

Bakshandeh: It’s important to understand how complex the population is. We don’t have a stagnant population. We have not only a multicultural population, but one that is also multi-genetic; and understanding where your patients are utilizing, what quality measures are needed [to measure their patient outcomes], and understanding how their needs are changing daily, is very important. So the way we’ve gone about looking at that is two-fold. One, in our command center in Orange, we’re using our data analytics structure, which is home-grown, and lab, pharmacy, EHR [electronic health record], claims, case management, all those forms of data, are coming into our analytics hub and are being redistributed out to the clinical teams, so they can execute care plans and intentions with a population that is changing on a daily basis. And real-time alerts allow us to provide that level of care management, which then leads to decreased utilization and improved health status.

But you can only do that through a model that can be executed on. So the second piece of this is our care management model, with physicians, mid-levels like physician assistants and nurse practitioners, and home care teams that can work with a case manager and social worker, and help lead towards a better outcome.

So you’re working on three levels, with data collection and analysis, followed by real-time alerting of your clinicians, coming from your command center; and then the level of physicians and their care teams in the clinics, followed by care going into patients’ homes, correct?

Bakshandeh: That’s correct.

Please tell me about the information technology infrastructure supporting and facilitating all this.

Kerry Matsumoto: The central nervous system [for our population health and care management work] is our analytics hub, which ingests and analyzes all of our partner and Alignment-generated data to create actionable alerts based on thousands of proprietary algorithms.  Think about this as the NASA control center where all information known about the patient is ingested, analyzed, and then shared with clinicians who need to know to take action and improve care.  We have centralized the analytics and alerts into this single engine instead of the traditional alert management in each individual ecosystem, which resulted in alert fatigue, alert conflicts between systems, etc.  You also need to execute around the core operational elements — you still have claims, eligibility, and all the operational and clinical delivery transaction systems such as utilization management, disease management and case management. We have Alignment Healthcare Centers, where we’re delivering care through employed physicians, nurse practitioners and medical assistants.  Then we enable the ecosystems and clinicians with vital information for delivery in the home, in the care center, in our partner provider offices, and in our markets.

So you’re managing all of this through a single nationwide command center, correct?

Matsumoto: Yes, we have a single nationwide command center hosted here in California. At the same time, command center information is decentralized to our markets and market partners —it’s delivered in all of our markets, and delivered to the desktops of clinicians, and we deliver that data to our physician partners.  Dr. Bakshandeh does virtual rounds with our clinicians in North Carolina and Dr. Henry Do does the same in Florida, and our senior medical officers and clinical teams in each market are all viewing the same patient information.

So at a very high level, you’re analyzing data from all three states?

Bakshandeh: That’s correct.

Matsumoto: Yes, and because this command center is such a vital element to our technology-enabled care model, we will continue to use it in all of our markets, for all of our delivery models. A key aspect of analytics is acquiring timely, complete, and high-quality data from all of our partners (CMS, health plans, providers, hospitals, consumer sources, etc.), and we place a high degree of focus from my team on getting that data ingested into our EDW [enterprise data warehouse], immediately cleansed and pushed into the command center.  We push to get all data that is available daily, or as near real-time as possible because it directly impacts patient care. Our command center will generate a real-time alert that can make a difference in our patients’ health status.

What are the biggest medical management challenges and the IT challenges, in doing this work?

Bakshandeh: From the clinical management standpoint, it’s regional culture change. The landscape is so different across the country in terms of culture, that the shift towards using data or data analytics in your day-to-day medical care is not something widespread yet, and that culture change is something that’s very difficult to implement, and I see a six-month learning curve towards helping physicians to understand the data and use it. When you’re in a more populous area, such as bicoastal, large cities, people are already doing this type of thing, and are more savvy. But as you move out into different parts of the country, the culture of the fee-for-service system remains [and hasn’t yet matured to embrace risk-based care delivery], and so it makes it difficult to penetrate those types of markets, where they’re like what Los Angeles was 20 years ago.

Matsumoto: I think one of the fundamental challenges—data has been around a long time, but acquiring timely, complete, high-quality data, is still problematic. HIEs [health information exchanges] and EHRs were supposed to transform the market, but at the end of the day, there’s still a lot of work to be done. The network path is there now. The challenge is finding a balance between insuring that you’re still maintaining HIPAA privacy, and actually delivering to the nuances of all the different instrumentation that’s needed, is still there.

But we also try to put ourselves into the position of the recipients of the data. Providers will say, I work with five different plans with different information systems—can’t you make this unabrasive to me? I think if you find the least-abrasive path that actually works within their ecosystem, that’s the solution, in terms of it being within their workflow.

So instead of sending them too many alerts that they then have to import and extract, we are working on new pathways to allow them to see Alignment data inside their EMR [electronic medical record] system while they are in the patient record, giving them direct access to our command center.  We’re not there yet, but because we employ physicians who work with physicians, we’re constantly trying to improve that workflow for PCPs to reduce abrasion

With regard to some of the areas where you’ve made progress [per the statistics in the introductory section of this article], where do you see that you’ve made some of the strongest gains?

Bakshandeh: An area where we’ve made excellence progress has been in original admissions per 1,000, and in readmissions—we’ve dropped those dramatically. Looking at Wake County in North Carolina, that rate had been 240-260 admissions per 1,000—and we finished off the year just under 170. And when you bring in the other chronic disease management outcomes into play, getting high blood pressure from uncontrolled to controlled, and hemoglobin a1c has improved in diabetics.

That goes back to getting the data to the care teams in real time, correct?

Bakshandeh: Right. We’ve extended that data through an app that can be downloaded. I’m still a practicing physician—I’m an internist and hospitalist—and I still use the data daily. A couple of examples: The command center has a 360-degree view of all the information we have on a patient—I can see the patient’s pharmacy data, clinical alerts, a global history of a member for as long as they’ve been a member with us. Example from over the weekend, where I didn’t have to work up a patient as much as I might have had to, which would have led to waste and a burden on the patient, who has dementia. But in 2011, he was treated for leukemia—but when he came into the hospital, his labs weren’t quite as off as they might have been. And because I had that data in front of me, and the patient couldn’t tell me because of his dementia and the family didn’t even know about the previous tests, I was able to do one simple blood test to confirm the recurrence of leukemia, and then produce a clear care plan. It was very powerful that I was able to pull that information right off my iPhone. That’s very powerful.

How do you see all of this work developing further in the next couple of years?

Bakshandeh: Where I see this going is the use of ‘big data,’ and non-healthcare data, like weather patterns, pollen counts, pollution counts, water quality: those types of data points will begin to be used in overall analytics, and will give us a better idea of those members that may be moving towards or prone to certain types of exacerbation in their health, and will leading to teams preventing initial symptoms, or controlling those symptoms before they get worse, and the more data we have and AI we use and the ability to move this data to care teams that understand how to action it, that will help us change the paradigm of healthcare and allow us as a healthcare system to provide better healthcare to the masses.

And what’s important to understand, from the IT leadership standpoint?

Matsumoto: All the things that Dr. Bakshandeh just said are right,  and they all need to be technology enabled. The way we’ve architected both the EDW and command center gives us flexibility—it allows us to quickly ingest new data sources like pharmacogenetics, operationalize new analytics,  and integrate new technologies.  We have been able to quickly flex our data analytics to meet the unique needs of our various lines of business described earlier.  But you still have to get the fundamental building blocks right, like your operational and clinical transactional systems, core infrastructure and security, EDW and analytics, service and change management, blended waterfall and agile software development, and data governance and ownership. And they have to be operationally excellent. I’m fortunate to have a strong IT leadership team who connect the dots with our operational leaders, and great business partners who understand our business, understand the connection between operations and technology, are passionate about the delivery to our members and patients, and believe in our mission.  This makes IT delivery that much easier.

What should our core audience of CIOs and CMIOs be thinking when they hear about your organization’s story?

Bakshandeh: For me, it relates to something I say every time I explain the command center, and that is that you  have to make your member touch count, because it might be the only member touch you make all year. So you have to use it to maximize your member’s health, your regulatory compliance, and your financial operations, and the only way to do that is through really excellent use of data and analytics.

Matsumoto: And you could take two different operators and give them the same data set—at the end of the day, if you give them data daily and it’s comprehensive and timely, but if they don’t do something with it, it won’t matter.   One of the reasons that we’re driving to five stars in medication adherence now when we weren’t a year ago, is that our pharmacist executive Ali Farrokhroo and his entire staff do real-time outreach to make sure that patients are med-adherent based on daily pharmacy data.


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Kaiser Creating Evidence-Based Complex Care Models

January 17, 2019
by David Raths, Contributing Editor
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Work aligns with recently published ‘Blueprint for Complex Care’

The National Center for Complex Health and Social Needs recently published a “Blueprint for Complex Care” to develop a collective strategy for promoting evidence-based complex care models. Recognizing that many patient issues have root causes that go beyond the medical, the Blueprint seeks to identify best practices for breaking down silos between the social care delivery system and healthcare.

Perhaps no health system has devoted as many resources to complex care as Kaiser Permanente. Its Care Management Institute, a joint endeavor between the Permanente Medical Groups and Kaiser Foundation Health Plan, has established Complex Needs as one of its national quality initiatives. It has named regional complex care leaders, created common quality measures across regions and established a complex need research arm called CORAL. (Kaiser Permanente has eight Permanente Medical Groups and regions, more than 12.2 million members, more than 22,000 physicians and 216,000 employees.)

In a Jan. 16 webinar presentation, Wendolyn Gozansky, M.D., vice president and chief quality officer, Colorado Permanente Medical Group and national leader for complex needs at the Care Management Institute, described Kaiser Permanente’s efforts and used some personal anecdotes to explain their goals.

She said Kaiser Permanenteis working on the concept of developing core competencies and tools to support a longitiudinal plan of care for patients with complex needs. “These are the folks for whom the usual care is not meeting their needs,” she said. “How do you recognize them and make sure their needs are being met?”

Gozansky gave an example from a patient she had just seen the previous wekend. This women had fallen and broken her hip. She had several chronic conditions, including significant asthma, yet she was not on an inhaled steroid.

“One concept I love from the Blueprint is that this field is about doing whatever it takes to meet the needs of the person in front of you,” she said. In speaking to the woman, she came to understand that singing in a church choir was the most important thing in her life, and the inhaler medication was making her hoarse and unable to sing.  She was fairly isolated socially except for church. “My goal was to get her rehabbed and leverage the patient-defined family that is supportive. Her goals are to sing, so we need to do what is possible to get her back to that. We have to capture that information, put it into a long-term plan of care. The goal is not to get her out of rehab but to get her singing in choir.”

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The health system has to work on care that is preference-aligned. The woman is not on a steroid inhaler but her care is preference-aligned. How does the health system assure that everyone knows they are doing the right thing?

Gozansky said the beauty of Permanente Medicine is that its setup involves an employed medical group focused on value, not volume. They can interact with health plan partners in delivery of new systems of care. “It is a virtuous cycle about value and person-centered care. This is what our complex needs team is trying to understand.”

She described the journey so far: In 2015 there were pockets of work being done across the eight Kaiser Permanente regions. In 2016 they established complex care as a national qualitiy iniative. “We knew we were not meeting these patients’ needs. We had to figure out the right way to do that.” They also realized that most of the previous research on the topic involved examples that were not in integrated systems such as Kaiser Permanente. “We had to figure it out in an integrated system,” she said.

 In 2017 they started working on cross-regional learning — for instance, taking a program from Colorado and trying it in Southern California. Then they sought to align quality measures. In 2018 they got funding to create CORAL, the complex needs research arm.  

The Care Management Institute has created a “community of practice” on complex care to break down silos within the organization and bring together research, operational and administrative executives. They also want to work with external stakeholders to make sure what they are developing is scalable, Gozansky said.

Mark Humowiecki, senior director of the National Center for Complex Health and Social Needs, also spoke during the webinar. He said one of the goals of the Blueprint was to get a clearer definition. Some people get confused about terms such as “hotspotting” and complex care, he said. He said there is a recognition that these patients’ needs are crossing traditional silos, so “there is a need to connect care for the individual but also at the system level.”

The goal, he added, is to create a complex care ecosystem by developing in each community system-level connections between social care delivery and healthcare, which in the past have operated too independently.  The five principles are that complex care is person-centered, equitable, team-based, cross-sector and data-driven. One of the Blueprint’s recommendations is to enhance and promote integrated cross-sector data infrastructures.

 

 


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NIH’s All of Us Program Teams with Fitbit for Data Collection

January 16, 2019
by Heather Landi, Associate Editor
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The All of Us Research Program, part of the National Institutes of Health (NIH), has launched the Fitbit Bring-Your-Own-Device (BYOD) project. Now, in addition to providing health information through surveys, electronic health records, and bio-samples, participants can choose to share data from their Fitbit accounts to help researchers make discoveries.

According to All of Us research program officials, the project is a key step for the program in integrating digital health technologies for data collection.

The All of Us Research Program, established by the White House in 2015, aims to advance precision medicine by studying the health data of 1 million diverse Americans over the next five years. One aim of the project is to include groups that have been historically underrepresented in research. As of September 2018, more than 110,000 people have registered with the program to begin the participant journey, and more than 60,000 have completed all elements of the core protocol.

The participants are sharing different types of information, including through surveys, access to their electronic health records and blood and urine samples. These data, stripped of obvious identifiers, will be accessible to researchers, whose findings may lead to more tailored treatments and prevention strategies in the future, according to program officials.

Digital health technologies, like mobile apps and wearable devices, can gather data outside of a hospital or clinic. This data includes information about physical activity, sleep, weight, heart rate, nutrition, and water intake, which can give researchers a more complete picture of participants’ health.” The All of Us Research Program is now gathering this data in addition to surveys, electronic health record information, physical measurements, and blood and urine samples, working to make the All of Us resource one of the largest and most diverse data sets of its kind for health research,” NIH officials said.

“Collecting real-world, real-time data through digital technologies will become a fundamental part of the program,” Eric Dishman, director of the All of Us Research Program, said in a statement. “This information, in combination with many other data types, will give us an unprecedented ability to better understand the impact of lifestyle and environment on health outcomes and, ultimately, develop better strategies for keeping people healthy in a very precise, individualized way.”

All of Us participants with any Fitbit device who wish to share Fitbit data with the program may log on to the All of Us participant portal at https://participant.joinallofus.org and visit the Sync Apps & Devices tab. Participants without Fitbit devices may also take part if they choose, by creating a free Fitbit account online and manually adding information to share with the program.

All of Us is developing additional plans to incorporate digital health technologies. A second project with Fitbit is expected to launch later in the year, NIH officials said, and this project will include providing devices to a limited number of All of Us participants who will be randomly invited to take part, to enable them to share wearable data with the program.

The All of Us research program plans to add connections to other devices and apps in the future to further expand data collection efforts and engage participants in new ways.

Related Insights For: Population Health

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NorthShore to Lead “Largest Primary Care-Based Genomics Program in U.S.”

January 14, 2019
by Rajiv Leventhal, Managing Editor
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The Chicago-based NorthShore University HealthSystem and genomics technology company Color are partnering on a new initiative that will aim to deliver the power of genomics to routine primary care at population scale.

Known as "DNA10K," the initiative will engage more than 10,000 patients and will be the largest known primary care-based genomics program in the U.S., according to officials who made an announcement last week.

The approach will build on NorthShore's years of experience in genomics and actionable electronic medical records (EMR) information, while providing access to Color's clinical-grade genetic testing and whole genome sequencing to inform patients about their risk for certain hereditary conditions, according to company executives.

“The knowledge will help patients learn about their genetic makeup, including risk factors for certain disease types such as common hereditary cancers and heart diseases. This insight will help NorthShore personalize care for each patient to support improved outcomes, prevention and overall health,” officials noted.

The announcement comes on the heels of a recent pilot between NorthShore and Color that looked to unlock the benefits of genetic information in routine care.

As officials explained, in less than two months, more than 1,000 patients signed up for the Color population health program as a part of their primary care visit, an adoption rate of more than 40 percent of those eligible and significantly beating expectations of the pilot program. “This is a strong indicator of patients' interest in understanding genetic factors that can influence health and the opportunity to work with NorthShore care providers to make more informed treatment or prevention decisions,” they attested.

Overall, the DNA10K initiative supports NorthShore's efforts to improve patients' health outcomes at a population level, with genomics as a foundation for informing individualized healthcare.

Patients who take advantage of the "DNA10K" offering will provide a blood sample, which is then analyzed in Color's CLIA-certified, CAP-accredited lab, and results are returned to healthcare providers and their patients. In addition to their NorthShore primary care provider, patients will also have access to board-certified genetic counselors and clinical pharmacists from Color and NorthShore, officials explained.

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