New Tool Helps inhealth Engage Patients, Manage Population Health Across Providers More Efficiently

Transcription

1 CASE STUDY inhealth New Tool Helps inhealth Engage Patients, Manage Population Health Across Providers More Efficiently While healthcare reform and the accompanying emphasis on population health management (PHM) has helped drive more business to inhealth, a Richmond, Virginia-based supplier of outsourced care management services, it has also created new concerns. Innovative payment models such as Accountable Care Organizations (ACOs) required inhealth to monitor and engage patients from multiple physician groups based on data from a wide variety of IT systems. One contract required the company to manage the care of 13,000 Medicare beneficiaries in an ACO whose 20 physician practices used electronic health record (EHR) software from five different vendors. inhealth needed a tool that would interface with all of the EHRs and additional practice management systems to track and document patients care, help build patient assessments, risk stratify the population, and message providers directly when appropriate. It proved a tall order. When a search for an off-the-shelf PHM tool that would support multiple systems came up empty, inhealth turned to Phytel for help in developing a new system that would meet their requirements. Working closely together, inhealth and Phytel developed what ultimately became Phytel Engage the healthcare industry s first PHM tool that can draw data from disparate systems and make it available in a single location to nurses, care managers and lifestyle health coaches to help them engage patients more efficiently and effectively. In its first use helping to manage the Healthy Weight program for employees of the Bon Secours Health System, Phytel Engage has helped lifestyle health coaches increase the number of enrollees they can manage by approximately 20 percent while helping more than 1,400 participants gain control of their weight. Crossing Provider Boundaries inhealth was founded in 1995 as a partnership between hospitals and physicians in Central Virginia. inhealth is an ACO enablement company that offers a continuum of services assisting health care providers to improve efficiency, patient access, outcomes and cost. Its It has been difficult to prove the value of care management both from a clinical and financial perspective. When you can drive processes that are not only aligned with physicians but evidence-based as well, you can create the type of results that improve outcomes in both areas. It isn t just the design of a clinical program but how it can be operationalized and how it fits into the workflow of physicians so it leads to hard outcomes that adds value. STEPHEN CAVALIERI, MD, Chief Medical Officer at Central Virginia Health Network

2 The goal (was) to develop a system that helps a care manager do their work by streamlining the intervention process using automation. Phytel already had the individual components. They just needed to be structured to work in our type of business. They saw the value and agreed to work with us on developing it. GERARD FILICKO, Senior Vice President of Clinical Services at inhealth core offerings include telephonic health and wellness coaching, condition management, physician practice support, health information technology, and population health infrastructure. Their suite of services is designed to improve patient engagement, enhance clinical outcomes and better align financial incentives for the new pay-for-performance world of healthcare. inhealth assists with both managing chronically ill patients and offering wellness programs designed to help enrollees live a healthier lifestyle so they can avoid becoming sick. The company has 20 years of experience in care coordination, care management, remote monitoring and telephone interventions for chronic patients and at-risk populations. In fact, inhealth worked with the Centers for Medicare and Medicaid Services (CMS) beginning in 2002 on the Medicare Care Coordination Demonstration project (MCCD), CMS s first attempt to demonstrate the benefits of managing a patient population by condition. inhealth performed a longitudinal study over a six year period on the impact of care management interventions on patients with congestive heart failure and other conditions. It was the organization s first foray into coordinated care, working with physicians, community resources, patients and caregivers to develop care plans and ensure patients were obtaining and taking their medications, following their physicians orders, eating properly and having their social needs met. This early work set the foundation for the services the company offers today. Much of the recent demand for inhealth s services has been driven by the heightened interest in PHM among physicians and hospitals as a way to improve the health outcomes of individuals and populations. Delivering PHM typically requires nurses, care managers and other professionals to be focused strictly on working with patients and patient populations. Rather than adding internal staff, healthcare organizations may opt to obtain this capability from an outside provider such as inhealth. Typically, this has meant the partner had to be granted access to the EHR and other relevant systems of a single physician group, hospital or healthcare system, to an employer s wellness portal or another data source. An interface would be created, and service provider would use that data to create patient registries, stratify risk among patient populations, communicate with patients, develop care plans and report back to the provider in order to deliver coordinated care. For inhealth, however, the process was more complex. We support multiple health systems rather than being dedicated to a single provider as internal nurse navigators or care managers within integrated delivery networks typically are, says Gerard Filicko, Senior Vice President of Clinical Services at inhealth. The patients and enrollees we work with live in different areas and see many different primary care providers. We have one contract with a group of 20 physician practices who have formed an ACO to manage 13,000 Medicare beneficiaries. They re using four or five different primary care physician EHRs. In addition, we have health coaching programs with enrollees who all work in several states. As a result, we had to coordinate care for patients across multiple systems. As we grew, the volume became overwhelming. We knew we needed to automate the process. Adding to the challenge was the fact that some patients were enrolled in multiple programs requiring care management. For example, a diabetic patient might also be part of a congestive heart failure cohort and need lifestyle coaching for weight loss. Depending on the patient, the data for that patient might be contained in three mutually exclusive EHRs. What was needed was a way to perform assessments, provide risk stratification, track, document and send messages back to the providers from one location. In 2012, with the interest in shared risk and other alternative payment programs growing, inhealth identified a need to implement a PHM platform that was independent of any EHR, wellness portal or other data source, allowing the organization to easily cross traditional boundaries. The organization put out an RFP and assessed the products available commercially in the marketplace. The closest matches came from products designed for case management at health payers. Yet these systems were claims-based, which meant it would be difficult to obtain the needed data.

3 With our old system there was no way to indicate whether a goal had been met, so there wasn t any way to measure the success. With Phytel Engage, if an enrollee meets a weight loss goal you can click on the met box and it is recorded. That ability to show the overall program success is not only important to Bon Secours but to other organizations that are considering using our services. ROB JOHNSON, Lifestyle Health Coach at inhealth We are a provider-centric organization, says Stephen Cavalieri, MD, Chief Medical Officer of Central Virginia Health Network, the parent organization to inhealth. We take on the role of an insurance company, but do it in partnership with the providers rather than the payers. We don t have ready access to claims data, and the payer technologies wouldn t provide the clinical information inhealth s nurses and other professionals would need to manage individuals and populations. A claims data-oriented system is also a poor choice because there could be a lag of three to six months until the next claim was submitted, which is not conducive to an effective PHM program. In addition, these systems wouldn t allow inhealth to care for patients enrolled in multiple programs to manage their health. They were also very expensive, in the seven-figure range, and then they d only get us to 70 percent of the capabilities we needed, Filicko adds. We wanted something that would take us 100 percent to where we needed to be, and for less than the cost of the systems we were considering. Having exhausted all the standard possibilities, it was time for us to do some out-of-the-box thinking. A New PHM Technology Is Born inhealth had been using the Phytel platform since 2009 to assist with automated outreach to patients in specific groups, insights on quality performance, care management and coordination and post-discharge transitions. In those cases, the various components were tied into the EHR or practice management (PM) systems of those groups. Through that time the two organizations had established a close partnership on many initiatives, and inhealth had seen the value the Phytel platform brings to PHM. Management at inhealth decided to approach senior leadership at Phytel with an unusual proposition. We asked if they would be interested in co-developing a PHM technology that was suited to support an ACO infrastructure that connects to multiple systems, with Phytel s existing platform components as the foundation, says Filicko. The goal would be to develop a system that helps a care manager do their work by streamlining the intervention process using automation. Phytel already had the individual components. They just needed to be structured to work in our type of business. They saw the value and agreed to work with us on developing it. Drawing on inhealth s more than 20 years of experience in delivering care management, Phytel built the technology that would become Phytel Engage. Among its unique capabilities is the ability to upload registry information from different EHRs and wellness portals so inhealth could extract the information needed, allowing care managers to operate independent of the source data systems. It also included the ability to document all interventions within Phytel Engage, and then feed that information back to the individual providers, saving care managers from having to document their work in each individual system. A standout feature is the modular assessment tool, says Filicko. In the past, when assessing patients nurses used many different, independent tools. Some were electronic, but others were paper forms or Excel spreadsheets that had been created by individuals. We worked with Phytel to consolidate all of that into 10 modules that provide consistency across the program and allow all types of assessments psycho-social, clinical, dietary habits, sleep habits and so forth to be performed in a single place. We select the modules that are appropriate to a particular disease state or program, and the nurses can easily click down the list. The system has helped consolidate our programs, data and care plans into structured units. It saves time and ensures all the needed information is easily accessible. While capturing information is important, Dr. Cavalieri sees Phytel Engage s ability to drive workflow for nurses, care managers and healthy lifestyle coaches as its greatest value.

4 When you combine care management, population health management, analytics and predictive modeling you really have all the information needed to best manage patients at your fingertips. With all the shifts occurring in the healthcare industry, the promise of that is gigantic. STEPHEN CAVALIERI, MD, Chief Medical Officer at Central Virginia Health Network It has been difficult to prove the value of care management both from a clinical and financial perspective, he says. When you can drive processes that are not only aligned with physicians but evidence-based as well, you can create the type of results that improve outcomes in both areas. It isn t just the design of a clinical program but how it can be operationalized and how it fits into the workflow of physicians so it leads to hard outcomes that adds value. Changing Lifestyles, Changing Lives inhealth s first trial of the new Phytel Engage product was in the Healthy Weight program it operates for the employees of Bon Secours Health System, a $3.4 billion non-profit Catholic health system sponsored by Bon Secours Ministries. The program encompasses 1,400 of Bon Secours 23,000 employees, and includes enrollees from all of its facilities in Virginia, New York, South Carolina, Florida, Kentucky and Maryland. Healthy Weight is a voluntary program designed to help Bon Secours employees, from the CEO to the guy who makes lunches, learn to live a healthier lifestyle, says Rob Johnson, a Lifestyle Health Coach at inhealth. They re not necessarily ill, they just want to improve their health overall, so we talk with them about nutrition, exercise, stress, sleep health, and many other things. We help them set and achieve their health goals. Originally, when inhealth s Lifestyle Health Coaches would contact an enrollee by phone they would need to take comprehensive freehand notes during the call. Johnson says they had a few templates and guidelines to follow, but for the most part they would ask questions, listen for the answers and type them in. It was difficult to any in-depth probing. That changed with the introduction of Phytel Engage. Before, if we asked an enrollee about their cardio program, we would have to type that they were doing cardio three days per week, Johnson says. Depending on the topic and the coach, sometimes we had to take handwritten notes with keywords and then go back to enter the documentation later. Now we can click a box for cardio exercise, enter a notation such as 3/week and the data is captured. It has sped up the whole process and made us more efficient, giving us more time to focus on each enrollee as well as handle more enrollees per day. Phytel Engage has added efficiency in other ways as well. For example, when coaches schedule a call, they can enter notes immediately to remind them an enrollee needs to set a new goal rather than having to review previous notes before the call to prepare. Phytel Engage also has questions built into the action set that can help guide the conversation. All the talking points are presented on one screen, and coaches can pick up where they left off rather than having to backtrack through their notes. Johnson has seen the difference the assessment tool makes in workflows first-hand. When I first started, performing the initial assessment of the enrollee was a very cumbersome task, he says. You had one tool for a sleep assessment, another for diet, another for exercise. You had to keep jumping between them not only to ask the questions but to use the information in the program. Now, everything we need is in one place. I can ask the sleep questions, then scroll down to the diet questions and so forth. When it s time to evaluate the information to put the plan together it s all right there. Another significant improvement is Phytel Engage s reporting capabilities, both for individuals and the progress of the overall program. With our old system there was no way to indicate whether a goal had been met, so there wasn t any way to measure the success, Johnson says. With Phytel Engage, if an enrollee meets a weight loss goal you can click on the met box and it is recorded. If you have 200 program enrollees who each set five goals, that s 1,000 total goals. You can run a report that shows 843 have been met, 100 have not been met and the remainder are changing. That ability to show the overall program success is not only important to Bon Secours but to other organizations that are considering using our services. As a result of these changes, inhealth s coaches can now manage a caseload of as many as 14 enrollees per day, an increase of more than 20 percent. In addition, they have helped over 1,400 program participants meet their weight loss goals.

5 We are so much more efficient and effective, Johnson says. It s the difference between driving an old beater and this year s Lamborghini. Digging Deeper Into Care Management inhealth s ultimate plan is to use Phytel Engage to enhance the care management services it delivers to providers, helping them take control of this critical aspect of population health rather than abdicating it to the health plans. This capability will be particularly important to ACOs that have struggled with it in the past due to a lack of trusted information. One of the advantages Phytel Engage brings is its integration with the Phytel platform. The beauty of the Phytel platform is that it can reach into the EHR and pull out all this information that a health plan doesn t have, and won t have in a claim for three or six months, says Dr. Cavalieri. In addition, there is all sorts of data that the Phytel platform can deliver, such as information about outreach, which the health plan may never obtain. Having access to all of this fresh data in one place, and making it available to care managers and physicians, will help fulfill the promise of accountable care. As with the Healthy Weight program, the reporting capabilities in Phytel Engage are expected to have a huge impact on current organizations using inhealth s services and those that are considering it. The reporting will provide a reliable way to measure the impact care management and PHM are having on patient populations, improving outcomes in a way that helps ACOs and other risk-sharing arrangements maximize the value they are delivering. When you combine care management, population health management, analytics and predictive modeling you really have all the information needed to best manage patients at your fingertips, Dr. Cavalieri states. With all the shifts occurring in the healthcare industry, the promise of that is gigantic. Solutions: Phytel Engage PRODUCT DISTINCTIONS BENEFITS + + Enables care management independent of EHRs, practice management or other systems + + Drives population health management + + Comprehensive, modular assessment tool consolidates individual tools in one place + + Flexible action sets can be quickly tailored to specific patient or health program enrollee populations + + Reports show status and/or progress of individuals, groups and populations + + Feeds data back to EHRs to keep physicians up-to-date on patient status + + Interoperable with the Phytel platform + + Solves data sharing issues that have prevented ACOs from achieving full value + + Improved efficiency increased number of enrollees healthy lifestyle coaches could work with by 20 percent + + Helped 1,400 enrollees achieve weight loss goals + + Reporting capabilities demonstrated value of the program Luna Road, Suite 600 Dallas, TX T F phytel.com