Population health: care for patients on or off the radar

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This is the second post in a three-part series about Baylor Scott & White Quality Alliance, a clinically integrated accountable care organization. Read part 1.

When you’re sitting in front of a doctor in an exam room, you expect that you and your health are the sole focus of that doctor’s attention. And any good doctor — or any health care provider — should in fact be solely focused on the patient in front of them. That patient’s health should be the only thing on their radar.

While that may make for a good health care experience for the patient at the time of the encounter, it does not constitute complete health care. That’s because providing a complete health care experience involves the broader responsibility of caring for patients who are not seeing a health care provider at any given moment. In other words, caring for patients who are off their radar.

This concept is at the heart of population health management, and one of the main ways Baylor Scott & White Quality Alliance (BSWQA) is seeking to create a new and better health care experience.

Powering Population Health

In health care, the term “population” refers to any distinct group of patients or potential patients. A population can include employees of a company, people of a certain age, those who live in a certain community or patients suffering from a particular condition.

Population health management is not only an imperative for BSWQA, but part of the Institute of Medicine’s Triple Aim. It’s also a new expectation of employers, payers and Centers for Medicare & Medicaid Services resulting from health care reform.

But in practice, how is it possible to actively care for patients away from the doctor’s office — or off the radar?

There are two key elements, the first of which is data-driven analysis to identify gaps in care. The second is Registered Nurse Care Coordinators.

With good data, BSWQA will be able to run reports to determine things like how many of its patients with high blood pressure are not on controller medication and which female patients over age 40 haven’t received a mammogram in the past year. BSWQA can see the vaccination status across its patient population. Armed with this information, BSWQA can then follow up with these patients.

And because BSWQA is an integrated accountable care organization that also includes hospitals, pharmacies and other providers across the entire health care continuum, data such as patients who fail to refill a prescribed medication will also be available.

For patients like Mr. Jones, who was featured in part one of the series, this is where population health management impacts individual health.

Big Data, Personal Attention

Mr. Jones, who suffers from chronic lung disease in addition to other conditions, takes an inhaled prescription medication to keep his airways open.

As a BSWQA patient who uses a pharmacy that also is a BSWQA member, should Mr. Jones fail to refill his prescription in a timely manner, his primary care physician’s office (which serves as his medical home) will know about it and can follow up.

This follow up is conducted by a BSWQA registered nurse health coach or care coordinator. These individuals are the second key to successfully managing population health and filling gaps in care.

A call to Mr. Jones simply to ask if he is consistently taking his inhaler medication is vital to keeping his health from deteriorating and landing him in the hospital.

The coach or care coordinator can explain to him why it is so important to consistently take his medication, and determine if there are any barriers preventing him from getting his prescription filled. If there is a barrier, such as transportation or cost, the care coordinator can work with him to overcome it.

The coach or care coordinator can continue to follow up with Mr. Jones on a weekly or monthly basis if he needs ongoing support.

Under the old model of care, this follow up never would have occurred simply because no health care provider would have known that he stopped his medication, and no one is responsible for tracking his health “off the radar.” Under the old model of care, Mr. Jones likely would have found himself back in the hospital at some point.

Gaps in care are disastrous for both health care quality and cost. Yet, registered nurse care coordinators who can help drastically reduce these gaps are not reimbursed by payers under the fee-for-service model.

So how do we finance population health care for patients? That will be the subject of the final part of this series.

About the author

Dr. Carl Couch
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Dr. Couch currently serves as President of the Baylor Scott & White Quality Alliance, an integrated network of more than 3,700 physicians, 43 hospitals, 31 surgery centers, 29 skilled nursing facilities, 10 home health agencies, three hospices and additional points of care aligned with Baylor Scott & White Health.

2 thoughts on “Population health: care for patients on or off the radar”

  1. Pingback: BSWQA: A tested way to control health care costs, ensure quality | Scrubbing In

  2. Pingback: Financing health care, not sick care, the BSWQA way | Scrubbing In

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Population health: care for patients on or off the radar