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BWH has always been known for innovation, particularly around clinical care approaches and research that seek to improve patient care.
The creativity with which the hospital is working to reduce costs, and simultaneously improve quality of care, is a continuation of BWH’s tradition of innovation. Population health management is one major tenet of these efforts.
So what exactly is population health management? It’s a strategy that aims to provide high-quality, efficient and affordable care for groups of patients using a care model that fosters a team-based approach.
Population health management is a transition from the way health care traditionally has been provided. For decades, health care has been organized around episodic interactions with patients. Population health management organizes care around patient health needs regardless of whether they are seeking health care. Additionally, the Partners eCare vision of “one patient, one record, one team, one statement” seamlessly aligns with effective population health management. Single patient records across Partners mean BWHC will have a more comprehensive understanding of our patients’ health and deliver better outcomes at lower costs.
“The changing health care market has given us an opportunity to develop improved models of care to manage patients over time,” said Jessica Dudley, MD, chief medical officer of the Brigham and Women’s Physicians Organization. “We are achieving this by coordinating patients’ care across the continuum. The Pioneer ACO and alternative quality contracts we’ve entered require us to manage a population of patients with regards to quality metrics, as well as overall medical costs.”
Brigham and Women’s Health Care (BWHC) is actively engaged in population health management through three key strategies: high-risk patient management, team-based care through the patient-centered medical home and medical neighborhood model, and targeted care redesign.
High-risk patient management: The Integrated Care Management Program
Imagine how difficult it must be to manage 13 different medications. Many of BWH’s high-risk patients take an average of 13 medications each and require a great deal of support navigating the health care system.
This is where the integrated Care Management Program (iCMP) comes in. High-risk patients in this program are assigned to a nurse care coordinator who is part of the patient’s primary care physician’s practice.
To manage every aspect of the patient’s care, the nurse coordinator works closely with all members of the care team, including a social worker, community resource specialist, primary care physician, nurse and others. The coordinator proactively identifies health risks, answers the patient’s questions and connects the patient with other clinical staff, including pharmacists who can educate the patient and family about managing many medications.
Team-based care: The BWHC Medical Neighborhood
There has been a lot of attention this past year on the medical home—a primary care model that relies on team-based care. Now, BWHC is also focused on developing what is called “the medical neighborhood,” which centers on streamlining and standardizing communication and consultation between primary care physicians and specialists for better patient outcomes.
It involves developing a consistent strategy for physician-to-physician communication and allows for more attention to be paid to coordinating a patient’s visits and collaboration between primary care and specialists in planning his or her care.
This could entail a primary care physician communicating with a physician or physician assistant in a specialist practice to plan a patient’s visit. The physician assistant helps the physician determine the appropriate tests to complete in advance of the visit, which specialist to see and the timeframe for the visit. This communication can reduce the time and expense associated with the wrong tests being performed, multiple visits to identify the correct specialty or multiple consults because the workup was not completed in advance of the first visit.
Targeted care redesign
The hospital’s third population health management strategy involves using clinical data to improve the delivery of care. The improvement process begins when an analysis of utilization data indicates a change in trend or a variation in the way a clinical service is provided.
BWHC then taps into the expertise of specialists with the most current knowledge of ambulatory and inpatient care and practices. In clinical areas that lack widely accepted evidence, expert panels review the available data and discuss common clinical practice in order to develop guidelines.
BWHC monitors outcomes and refines the guidelines as more information becomes available. This approach has successfully been used to redesign post-operative care for patients who receive a coronary artery bypass graft as well as for total knee replacements.
This article is the first in a BWH Bulletin series focused on exploring the three population health management strategies. Watch for more in-depth coverage of these strategies in future issues of BWH Bulletin.