Despite its efforts to identify rising- and at-risk patients in the midst of the pandemic, communicate with their primary care physicians about these patients, and generate patient-facing education, Southwestern Health Resources, the largest health system in North Texas, found many patients still were delaying physician visits for chronic disease management and preventive care because of fear of COVID-19.

THE PROBLEM

The country has seen death rates rising from episodes such as heart attacks and strokes, while cancer screenings have plummeted. The Southwestern Health team decided it needed to do more to ensure the population it serves receives the care they need safely and promptly. With that, they launched a "closing the care gaps initiative" in the late summer and early fall of 2020.

"We used our predictive analytics data to identify rising-risk and high-risk patients, reminded them of their need to pursue routine care appointments, screenings, tests and visits, and provided the lists to physicians so they also could follow up to encourage in-person or virtual appointments," said Dr. Jason Fish, chief medical officer at Southwestern Health Resources.

"In addition, we worked with third-party partners to send in-home test kits to patients so they could provide crucial information that would support optimal care, such as fecal test kits and diabetes test kits, as well as offering more options for care in the patients' homes, such as diabetic eye exams," he added.

PROPOSAL

In general, healthcare organizations aren't short of data. Rather, it's that people don't act on the data that's available, Fish said.

"Our predictive analytics technology team helped move us quickly from retrospective reporting to being able to effectively harness data already in our system to develop predictive analytics for the populations we serve," he explained. "We needed to be able to use our data to prospectively apply resources where they're needed in a timely fashion for maximum impact.

"For example, if we can identify patients who are at higher risk of admission, readmission or medication noncompliance, and coordinate proactive and preventive care for those patients, we will end up with better patient outcomes and therefore a lower total cost of care," he added.

"A key component is how we can identify patients who need additional resources and support, whether it's home-based interventions, pharmacy support, etc., at any level."

Dr. Jason Fish, Southwestern Health Resources

The critical element is how the provider organization uses data to identify patients who are likely to need additional resources and support now or down the road, whether through home-based interventions, pharmacy support, more PCP visits and other means.

"We now have the ability to integrate clinical EHR data, claims data and public health data to find the meaningful clinical information and deliver it to providers at the point of care," he noted. "At Southwestern Health, we can use data to identify gaps, set triggers and reminders that enable providers to intervene before patients have an acute – and costly – illness.

"We use predictive analytics to improve the experience for both physicians and patients and to lower the cost of care for payers and other purchasers of health benefits," he said.

MEETING THE CHALLENGE

Southwestern Health's population health services provide staff with a health management system that enables information and improvements to be rapidly scaled across the network. An extensive data repository (from physician EHRs that now include nearly three million unique Dallas/Fort Worth patients), data integration and analytics all feed into a robust health information exchange system that helps physicians improve performance.

"Using information and resources from our population health services, individual physicians and physician groups are supported in improving quality and safety, as well as reducing the total cost of care," Fish said. "This supports opportunities to build improvements of individual providers and groups, as well as the overall performance of the physician network."

There are three areas that make up Southwestern Health's population health and clinical integration performance analytics:

• Analytics architecture, built to include claims-based analytics, supplemented by real-time (or near-real-time) physician practice EHR data, scheduling data and hospital ADT information (including non-SWHR hospitals).
• Opportunity analysis. Identifying patients who need PHSC support services, including high-risk care management, preventive care, incorporation into disease-management programs, referral guidelines and utilization-management programs.
• Direct patient engagement. The ability to directly engage patients through personal and automated means in order to track adherence to care-management protocols and provide additional support services.

"A key component is how we can identify patients who need additional resources and support, whether it's home-based interventions, pharmacy support, etc., at any level," Fish said. 

"Often you wait until someone is already hitting the health system. They're in an emergency department, they're admitted, they've had surgery. They've had some acute process going on, and when we identify those folks, more and more we've been relying on an inpatient care coordinator to start that process as soon as the patient is in an inpatient facility.

"That's when we can then start to apply resources," he added. "Of course, we would much rather prevent the accidents from occurring in the first place."

The organization is starting to integrate data from multiple sources. For example, social determinants of health can be key factors in a person's overall health. Many people think of SODH as economically disadvantaged populations, and that's part of it.

However, social determinants impact health outcomes across all socioeconomic strata, across all racial groups and across all different cultural backgrounds. Therefore, Southwestern Health had to adapt its care-management resources to meet patients' social needs, as well as their healthcare needs.

RESULTS

"A prime example is through our colorectal screening results," Fish noted. "Nearly one-third of 108,000 colorectal test kits we distributed were returned, and approximately 5% of those were positive, meaning they showed a blood antigen that is associated with colon cancer.

"From there, follow-up was conducted with patients who tested positive for a blood antigen associated with colon cancer, and Southwestern Health reported a 32% gap closure rate," he said. 

"Participating clinics exceeded their original target goal of 25% while further strengthening the patient and provider relationship and opening the door for open, honest communication about colorectal cancer."

Southwestern Health also distributed more than 200,000 targeted communications to patients at risk of heart attacks and strokes, urging them to avoid delaying care. Using advanced analytics from claims and EHR data, the organization disseminated more than 250,000 amplified messages to patients and members in high-prevalence Zip codes that highlighted prevention of COVID-19 infections in the community.

"Strategic partnerships with testing lab vendors allowed for in-home testing for diabetes A1C, nephropathy, and colorectal cancer, and facilitated in-home testing for diabetic eye exams," Fish explained. 

"Southwestern Health established a partnership with Univision to reach more than 5.5 million people with messaging delivered by Southwestern Health network physicians to encourage the Latino population not to delay necessary care," he said.

The health system "identified more than 150,000 patients among their members who are at risk for cardiovascular disease and serious cardiac events," he added. "Emails and letters were sent to 150,000 patients to educate them about the symptoms of stroke and heart events, and when to seek emergency care."

The post-acute care initiative established a model for performance improvement and a tiering system for high reliability and preferred PAC providers, he added. It reduced the per member/per year total cost of post-acute care by 5% – or an estimated $6 million in savings related to reduced unnecessary utilization for 2019. Savings have continued to increase in the years since.

ADVICE FOR OTHERS

Fish advised his peers working with predictive analytics to be open to new ideas. He said Southwestern Health is continually piloting, testing and scaling innovations that demonstrate the feasibility of a value-based health system while demonstrating the ability of population health management across the continuum to lower the total cost of care.

"Take the SDOH, which has always been amplified, and recently became exacerbated during the pandemic," he added. "As a clinically integrated network, we are continually evolving how we address these unique needs of the community. We have learned to leverage the power of data analytics for more robust and proactive population health management."

For example, the organization can survey patients to understand the reason for avoiding healthcare appointments and look jointly for possible solutions, he said.

By capturing data at every touchpoint, Southwestern Health can provide value for patients, physicians and payers, even during the pandemic.

"Data helps identify gaps in care to ensure at-risk patients get routine care, the elderly are being cared for at home, and that all eligible patients are getting their routine vaccinations," he concluded. 

"During the pandemic, data aggregation and analytics have enabled us to conduct outreach to more than 10,000 patients in high-prevalence Zip codes and manage screenings of COVID-positive patients for SDOH."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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