Making strides in population health
As the march continues to change the way health care is provided and paid for in this country, Emory Healthcare is making measurable strides in the art of population health management, which entails cutting health care costs and improving outcomes on a large scale.
|Richard Gitomer, Cathi Durham
"It's clear that the fee-for-service world is going away," says Richard Gitomer, president and chief quality officer of the Emory Healthcare Network (EHN). In that world, you wait for patients to get sick and then react. In the new world, you provide proactive care to help patients stay as healthy as possible. "You ensure they receive the care the provider intends, and you reduce the need for unintended care, such as ER visits and hospital admissions."
What's also clear, he says, is that fee-for-service payments are going away. By 2019, 25% of payments from Medicare (the world's largest health insurer) will need to be in an alternate payment model for the provider to receive an incentive bonus and avoid a penalty. By 2023, the number climbs to 75%.
Need for high volume: To keep patients healthy on a population scale, you need a broad network of providers and patients, says Gitomer. Thus, a key element in Emory's population health strategy is the EHN itself, which has some 200 sites and 2,000 physicians. EHN encompasses all of Emory Healthcare's components, including faculty practices in the Emory Clinic, Emory-owned practices in Emory Specialty Associates, and a growing number (currently 460) of non-Emory-employed private practitioners, both generalists and specialists. "We engage these providers in our population management efforts," says Gitomer, "and they get access to value-based contracts with payers that we have negotiated via the EHN."
To participate in the EHN, such providers must meet certain Emory requirements. They must have an electronic medical record that can interface with Emory's health information exchange, for example, and they must participate in Emory care coordination and other quality-improvement initiatives.
Medical homes: Another key element in Emory's strategy is what Patrick Hammond, EHN CEO, calls the "population management university," a training program that helps Emory practices learn the new skills required for population management and gain recognition as a medical home by the National Committee for Quality Assurance (NCQA).
In a medical home, care is team-based and highly coordinated, with special outreach to high-risk patients, such as those with chronic conditions like diabetes. The team works to ensure that patients fill prescriptions and take their meds and that they have the tools and understanding needed to take good care of themselves. Providers offer continuous, as-needed access, either in person or via the patient portal.
Emory already has two NCQA-recognized medical home primary care practices (one at 1525 and one in Dunwoody). According to practice transformation coach and RN Cathi Durham, 10 more are slated to come online next spring, with still others in the pipeline.
Durham meets monthly with the team in each of the 10 practices and conducts periodic all-day collaboratives to bring the teams together for education and networking. Their focus is continual improvement in quality and efficiency. "We help analyze practice service data so teams can get feedback on results, and we have software that soon will allow practices to pull such data themselves."
Emory is hiring two more coaches like Durham, each of whom will work with seven to 10 practices. "The goal is to have NCQA recognition for all 92 EHN primary care practices," says Durham. But getting recognition is not the end game because quality improvement is ongoing, she says, and it's also not just for primary care practices. Emory plans to create a medical "neighborhood" in which EHN specialty practices adopt characteristics of medical homes and receive NCQA recognition as well.
Value acceleration: There are other important elements to Emory's strategy in population health, including efforts by a team of experts, led by Gregory Esper, director of new care models, to define and redefine best practices one "clinical bundle" at a time—what Gitomer refers to as the "blocking and tackling" of health care. Esper's team is looking at a various questions: How can we coordinate better to facilitate earlier discharge from the hospital while also reducing readmission rates for at-risk patients? How do we implement evidence-based protocols across multiple surgical disciplines so that we can improve outcomes and reduce cost of care?
Building an infrastructure in population health may be painstaking and time-consuming, but it's already showing results, says Hammond. "We looked at our sickest patients, those who averaged 11 admissions and nine ER visits per quarter. After improving their coordination of care, these numbers are down to one each per quarter."
Coordinating care for veterans with dementia
|Corrine Abraham, Anne Tomolo
Faculty members Corrine Abraham (nursing) and Anne Tomolo (medicine) have worked together in care and training at the Atlanta VA Medical Center (VAMC) for three years now, and their latest collaboration is a new center to coordinate care for patients with dementia.
The Specialty Care Education Center of Excellence for Cognitive Disorders, co-directed by Abraham and Tomolo, is funded by a $1.5 million three-year award from the Department of Veterans Affairs. In addition to coordinating care, it will provide a platform for teaching Emory nursing students and medical residents and fellows and social work students from other schools as part of interprofessional teams.
"The center will help bridge the gap for patients by integrating telehealth and shared appointments with team members specializing in neurology, psychiatry, geriatrics, palliative care, and social work," says Abraham, who is coordinator of evidence-based practice and innovation in nursing at the VAMC. "Students will learn about specialty care for cognitive disorders with an emphasis on teamwork, collaboration, and quality improvement."
"It's important to have an entity that brings specialists and students together around patients and their families," says Tomolo, who is chief of quality medicine and site director for postgraduate training in quality and safety at the Atlanta VAMC. "The other crucial piece is integrating quality improvement into the curriculum so that students learn how to build a clinical model and improve practice together."
Currently, veterans with dementia enter the Atlanta VAMC through multiple pathways, either via their primary care physician or various specialists. The new center will consolidate their care.
Instead of being evaluated by different specialists in different locations at different times, veterans first will be assessed via phone by a nurse coordinator before they come to the VAMC for a clinic visit. Next, specialists in neurology, geriatrics, psychiatry, and eventually palliative care will decide as a group how to manage patients through shared appointments. After seeing patients, the care group will meet to develop a care plan and refer veterans and caregivers to VA and community resources. The nurse coordinator will follow up regularly by phone to help manage their care.
During clinic visits, nurses and social workers will meet with family caregivers to assess their needs. One option for caregivers will be Tele-Savvy, an online distance-learning education program for dementia caregivers developed by Emory nursing professor Ken Hepburn and colleagues. The program provides self-guided individual instruction and connects groups of caregivers for weekly chats online. Hepburn is now instructing center staff on using Tele-Savvy as an intervention.
"It's an ordeal to get a patient with advanced dementia out of the house to go to the doctor," says Abraham. "Tele-Savvy will provide caregiver support in the home and through peer-to-peer support, which will help caregivers cope with their loved ones' condition and manage their own anxiety and depression."
The center is currently in startup phase, and Abraham and Tomolo are immersed in hiring new staff, developing a program evaluation plan with public health faculty member N-goc Cam Escoffery, and piloting a curriculum for psychiatry residents from Morehouse School of Medicine, also a partner in the center. Other Emory faculty involved in the center include Nirmala Bangalore and Thomas Wingo, who lead existing VAMC clinics in mild cognitive impairment and neurology, respectively.—Pam Auchmutey
Emory to partner with regional big data hub
Emory will be a health care research partner in the new South Big Data Regional Innovation Hub directed by Georgia Tech and the University of North Carolina's Renaissance Computing Institute. The hub will serve 16 Southern states and the District of Columbia.
The hub is part of the National Science Foundation's four Big Data Regional Innovation Hubs announced earlier this month, formed to build public-private partnerships to address regional challenges through big data analysis.
Michael Zwick, AVP for research in the Woodruff Health Sciences Center, assistant dean for research in the medical school, and core director of ACTSI's research technologies program, will represent Emory on the South BD Hub Steering Committee.
A number of existing big data projects at Emory will collaborate with the hub.
|Daniel Brat, Andrew Post
For example, Daniel Brat, chair of biomedical informatics in the medical school and director of the Cancer Tissue and Pathology Shared Resource at Winship, is investigating biomarkers of human gliomas in an in silico Center for Brain Tumor Research, using large data sets such as the Cancer Genome Atlas. In a recent large national study led by Brat, researchers found that molecular diagnostics can be much more precise and consistent than traditional microscopic classification in diagnosis and prognosis of brain tumors.
Another hub collaborator in biomedical informatics is Andrew Post, interim director of ACTSI's Biomedical Informatics Programs. Post is leading efforts to create coordinated access to and management of clinical data across Emory and multiple medical centers in the Atlanta area and across the Southeast. A major component of the program is the i2b2 clinical data warehousing system at Emory and Morehouse School of Medicine. Post also leads ACTSI's efforts in the NIH-supported Accrual to Clinical Trials network, which includes more than 21 academic medical centers. Read more.