Baptist Health South Florida operates a network of 11 hospitals covering four counties. It also includes numerous ambulatory facilities, urgent care centers and emergency departments to provide comprehensive healthcare services across the region. And its Population Health Service Organization focuses on improving the health outcomes of a specific population by coordinating and integrating healthcare services across the continuum.

One of the entities the PHSO employs to accomplish value-based care is Baptist Health Quality Network. BHQN is a clinically integrated network affiliated with Baptist Health South Florida, the region's largest healthcare organization. Bringing together primary care physicians, specialists and hospitals, BHQN is dedicated to high-quality, patient-centered care.

THE PROBLEM

As a clinically integrated network and accountable care organization, Baptist faced significant challenges in managing the health of its patient population effectively before implementing population health management technology.

"One of our primary issues was the fragmented nature of patient data across multiple provider organizations and electronic health record systems," said Milady Cervera, vice president, population health and physician integrated networks, at Baptist Health South Florida. "This lack of interoperability made it difficult to gain a comprehensive view of our patients' health status, care history and ongoing needs.

"Without a unified data platform, we struggled to identify high-risk patients, track care gaps, and coordinate care effectively across our network of providers," she continued. "Additionally, we grappled with the complexity of risk stratification and predictive analytics. Our manual processes were inadequate for accurately identifying patients at risk of deteriorating health or high utilization."

This limitation hampered the organization's ability to implement targeted interventions and preventive care strategies, which are crucial for improving outcomes and controlling costs in value-based care models.

"Another significant challenge was the lack of real-time insights and actionable data," Cervera noted. "Our providers often made decisions based on outdated or incomplete information, leading to inefficiencies, duplicated services and missed opportunities for early intervention. The absence of a robust analytics platform also hindered our ability to measure and report on quality metrics, which is essential for contract performance and shared savings programs.

"Furthermore, we struggled with patient engagement and care coordination," she added. "Without advanced communication tools and a centralized care management system, it was challenging to keep patients actively involved in their care plans, ensure smooth transitions between care settings, and facilitate collaboration among our multidisciplinary care teams."

With a goal to engage patients beyond the traditional hospital setting, staff believed they needed a technology that would span the continuum of care and interact with and engage patients in all care settings. This included but was not limited to wearables, post-acute management, remote patient monitoring to track patient outcomes post discharge, and more.

"These issues collectively impacted our ability to meet the Triple Aim of improving patient experience, enhancing population health and reducing per capita healthcare costs," Cervera explained. "We recognized that overcoming these challenges would require a sophisticated population health management technology capable of integrating data, providing actionable insights, and supporting our care teams in delivering high-quality, coordinated care across our network."

PROPOSAL

First, the proposed population health management technology provided a unified data platform, Cervera said.

"The technology offered the ability to integrate patient data from multiple provider organizations and EHR systems, creating a centralized and interoperable platform," she continued. "This would enable a comprehensive view of each patient's health status, care history and ongoing needs, which is essential for effective care coordination and management.

"The technology also offered advanced risk stratification and predictive analytics, which use sophisticated algorithms and advanced machine learning designed to accurately identify high-risk patients and predict potential health deteriorations," she added. "This proactive approach would allow for the implementation of targeted interventions and preventative care strategies, resulting in improved patient outcomes while controlling costs."

The vendor also provided real-time analytics and dashboards, which offer up-to-date, actionable data for both network leadership and providers. The point-of-care system offered would aid providers and care team members in making informed decisions, reducing inefficiencies, avoiding duplicated services and seizing opportunities for early intervention, Cervera said.

"The advanced communication tools and a centralized care management system facilitates enhanced patient engagement and care coordination by involving the patient in their care plans, ensuring smooth transitions between care settings, and promoting collaboration among multidisciplinary care teams," she explained. "This would enhance patient engagement and improve care coordination across the network."

MEETING THE CHALLENGE

As a clinically integrated network and ACO, Baptist proposed implementing a comprehensive population health management technology comprising: Cerner HealtheIntent (now known as Oracle Health Data Intelligence); InNote, InCare and InGraph from Innovaccer; Salescloud from Salesforce; and a remote patient monitoring system to address the challenges. This integrated system was designed to resolve the data fragmentation issues, enhance analytics capabilities, improve care coordination and significantly boost patient engagement across the entire care continuum.

"Cerner's HealtheIntent serves as the foundation of our population health management strategy and supports system-wide population health initiatives," Cervera explained. "HealtheEDW [now part of the Oracle population health platform] aggregates data from our various EHR systems, payer claims data sources and the RPM system into a unified data warehouse.

"This centralized platform provides us with a holistic view of our patient population, including data from various care settings and patient-generated health data, enabling more effective care coordination and informed decision making," she said.

To complement HealtheIntent, Baptist incorporated Innovaccer's data activation platform and advanced analytics capabilities.

"We were excited about its machine learning algorithms that generate actionable insights from our consolidated data," Cervera recalled. "Innovaccer's Best in KLAS point of care solution, InNote, solved one of our largest challenges: delivering actionable insights to the providers at the point of care.

"The solution is in place today and being used by physicians and their support staff and has already shown improvements in both risk coding outcomes and quality measure gap closure for the network," she continued. "The vendor's predictive modeling features will help us identify patients at risk of health deterioration across various care settings, suggesting proactive care measures."

Salesforce is BHQNs patient outreach and documentation system to manage interactions with Baptist's network physicians including contract management, engagement and productivity. Salesforce manages BHQN's patient interactions and tracks outreach and follow-through efforts.

"Even with our robust implementation of Cerner HealtheIntent, Innovaccer and Salesforce, we still face some challenges," Cervera noted. "Data integration across these platforms isn't always seamless, leading to occasional information gaps or delays. We sometimes struggle with alert fatigue among our care teams due to the high volume of data and notifications generated by our systems.

"Additionally, patient adoption and consistent engagement with our RPM tools remain ongoing challenges, particularly among certain demographic groups," she continued. "Lastly, while our analytics capabilities have greatly improved, we still grapple with translating all these insights into consistently actionable interventions across our entire patient population."

Through this technology stack, Cervera hopes to overcome these challenges.

RESULTS

With the Innovaccer InNote system deployed to providers across 38 practices, Baptist has experienced a 7% increase in coding gap closure rate.

Using all three vendors' systems, Baptist developed the HUB model: a geographical resource deployment for nurses to partner one-to-one with physician offices and better manage the care coordination of their patients. The HUB model leverages the HealtheIntent platform to identify patients post discharge and document care coordination activities, among many other initiatives.

"By using HealtheEDW, we've implemented a customizable risk stratification algorithm based on clinical and claims data to proactively identify patients for outreach," Cervera reported. "That outreach is then integrated with Salesforce for any scheduling and follow-up needs the patient may have. Innovaccer informs the nurses and providers as to the most at-risk patients and those to target for interventions including identifying gaps at the point of care, ensuring timely closure.

"Through this implementation, we've realized a 17% increase in annual wellness visit completion rates for our Medicare populations, and 9% improvement in commercial," she continued. "As well as a 20% improvement in transitional care management revenue capture and 145% increase in chronic care management revenue capture."

Further enhancements are being made to the model to improve upon quality measure performance rates and readmission rates and, ultimately, reduce total cost of care.

ADVICE FOR OTHERS

"When considering population health management technology, healthcare provider organizations should prioritize several key factors," Cervera advised. "First, there must be a system-wide population health strategy with clear prioritization, aligning it with your organization's overall goals and securing executive buy-in by articulating the value proposition of value-based care.

"Engage physician leadership throughout the process, as their buy-in is crucial for successful adoption," she continued. "Also, ensure you have appropriate teams, resources and skill sets to support the advanced technology. Individuals with subject matter expertise in healthcare data and population health specific initiatives – for example, total cost of care models, bundled payments, post-acute data management, etc. – are critical in roles such as data analysts and healthcare informatics specialists."

A culture of continuous improvement and movement toward clinical standardization of care is required to effectively leverage population health management tools, she added. This includes developing a comprehensive data governance and change management strategy to ensure stakeholder buy-in and smooth workflow integration, she said.

"Assess your organization's readiness for innovation and be open to new approaches in care delivery and patient engagement," she recommended. "When selecting technology, focus on interoperability, scalability and patient engagement features that extend care beyond traditional settings.

"Remember, implementing population health management technology is a long-term commitment requiring ongoing optimization and support to fully realize its benefits," she concluded.

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