ACO offers population health pointers for beginners
Advocate Health Care in Illinois has 13 hospitals and one of the largest accountable care organizations in the U.S., including a Medicare Shared Savings ACO, a combined full-risk HMO and a commercial ACO contract with Blue Cross & Blue Shield of Illinois. All in all, its accountable care footprint covers 528,000 lives. With population health management at the center of ACO quality metrics, the health system is well acquainted with data analytics. And they have some tips for those getting started with population health.
Rishi Sikka, MD, is one of the individuals in charge of it all.
Sikka, the senior vice president of clinical transformation for Advocate Health Care, is charged with the oversight of clinical operations, business intelligence and big data initiatives at the health system. He will be speaking at the HIMSS Media and Healthcare IT News Big Data & Healthcare Analytics Forum in New York June 18, discussing population health strategies.
Looking to get started with population health at your organization? Sikka has some tips that may come in handy.
First things first. You need to establish the "why." It's basic, but an essential part of the population health foundation, and one often neglected, said Sikka: "Why are you on this journey for population health?" That answer will help establish the goals you want to get out of population health. Once you have them defined, then comes the strategy to achieve those goals.
Another key step? Before you get started with it all, put all the data together. "You really need to try to bring all your data together in one location centrally that is normalized, standardized and reconciled along the single master patient index," said Sikka. "Because if you continue to look at your data in silos, then your care will be fractured in silos, and you won't really achieve the goals of true continuum of care."
Know and talk about where both the internal and external data resides and how you'll bring it together in one place, he explained.
Next, don't be so quick to jump to the predictive models, said Sikka. You need to better understand the present conditions of your patient populations before you focus on the future.
"The very first thing you need to do from an analytics standpoint is just understand the current state of your population," he said. Ask, "What is happening today?" he added, and "you'll actually find that they're quite challenged to answer that."
Instead of thinking about predicting readmissions, for instance, do you know about the populations being readmitted today? This step is about "understanding a state of being."
Then, when you have this down, you can move onto predictive models. But remember: "If you just have all these models and data, it's just an academic exercise." To really improve the care of patient populations and address cost issues, "you need to take the model, build it into workflow and generate some type of action, an actionable impact on the patients you're caring for."
TABLE: 2013 results from Advocate Physician Partners ACO (Data via PulsePilot)
| Description | Measure | Percentile | Category |
|---|---|---|---|
| Description | Measure | Percentile | Category |
| How Well Your Doctors Communicate | ACO-2 | 90th+ | Patient/Caregiver Experience |
| Patients' Rating of Doctor | ACO-3 | 90th+ | Patient/Caregiver Experience |
| Health Promotion and Education | ACO-5 | 90th+ | Patient/Caregiver Experience |
| Health Status/Functional Status | ACO-7 | 90th+ | Patient/Caregiver Experience |
| Risk Standardized, All Condition Readmissions | ACO-8 | 90th+ | Care Coordination/Patient Safety |
| Tobacco Use Assessment and Cessation Intervention | ACO-17 | 90th+ | Preventive Health |
| Depression Screening | ACO-18 | 90th+ | Preventive Health |
| Getting Timely Care, Appointments, and Information | ACO-1 | 80-90th | Patient/Caregiver Experience |
| Access to Specialists | ACO-4 | 80-90th | Patient/Caregiver Experience |
| Shared Decision Making | ACO-6 | 80-90th | Patient/Caregiver Experience |
| Medication Reconciliation | ACO-12 | 80-90th | Care Coordination/Patient Safety |
| Proportion of Adults who had blood pressure screened in past 2 years | ACO-21 | 80-90th | Preventive Health |
| Percent of beneficiaries with diabetes whose HbA1c in poor control (>9 percent) | ACO-27 | 80-90th | At-Risk Population Diabetes |
| Beta-Blocker Therapy for LVSD | ACO-31 | 80-90th | At-Risk Population HF |
| Percent of PCPs who Qualified for EHR Incentive Payment | ACO-11 | 70-80th | Care Coordination/Patient Safety |
| Falls: Screening for Fall Risk | ACO-13 | 70-80th | Care Coordination/Patient Safety |
| Percent of beneficiaries with hypertension whose BP | ACO-28 | 70-80th | At-Risk Population Hypertension |
| Percent of beneficiaries with IVD who use Aspirin or other antithrombotic | ACO-30 | 70-80th | At-Risk Population IVD |
| Adult Weight Screening and Follow-up | ACO-16 | 60-70th | Preventive Health |
| Mammography Screening | ACO-20 | 60-70th | Preventive Health |
| Patients who meet all the following measures: Low Density Lipoprotein (LDL) ( | ACO-23 ACO-26 ACO-25 ACO-22 ACO-24 | 60-70th | At-Risk Population Diabetes |
| Percent of beneficiaries with IVD with complete lipid profile and LDL control | ACO-29 | 60-70th | At-Risk Population IVD |
| Influenza Immunization | ACO-14 | 50-60th | Preventive Health |
| Colorectal Cancer Screening | ACO-19 | 50-60th | Preventive Health |
| Patients who meet all the following measures: ACE Inhibitor or ARB Therapy for Patients with CAD and Diabetes and/or LVSD, Drug Therapy for Lowering LDL Cholesterol | ACO-33 ACO-32 | 50-60th | At-Risk Population CAD |
| ASC Admissions: COPD or Asthma in Older Adults | ACO-9 | 40-50th | Care Coordination/Patient Safety |
| Pneumococcal Vaccination | ACO-15 | 40-50th | Preventive Health |
