John Muir Health aligns IT and care management to bolster population health
Successful care coordination is critical to achieving population health management. But coordinating care across a population of any size or makeup is no easy undertaking.
John Muir Health, a hospital system based in Walnut Creek, California, has an executive dedicated to this process – Christy Kaplan, vice president of care coordination and integration. And care coordination has become exceedingly important as the health system moves quickly from a volume to value business model, with many full-risk agreements in place.
“When we started that change, the approaches to teams in volume care versus value care were polar opposite,” Kaplan said. “Once the health system had the insight to create my position, a service line on care coordination across the continuum, we then pulled all of the caregivers together, including things like home health and wellness and chronic diseases, so we all are in the same service line. That started the conversation of what do we need to do to get these folks to connect and manage populations, not just patients on a case-by-case basis.”
Learn more at the Pop Health Forum 2016 in Chicago September 12-13.
Kaplan added that enhanced care coordination simply is the right thing to do because even though increased financial risk perks everyone up, evidence-based medicine and other integrated care practices are the best things for patients.
“That’s when we started looking at communication and technology and care management and merging all of these things together,” she said.
Ensuring patients were appropriately connected to the right care team members and benefitting from evidence-based care programs and services has been key for John Muir Health’s care coordination efforts.
“This involves a population approach to identifying patients where we deployed risk stratification and utilization and merged all the patient touch-points to understand what is going on with individual patients,” Kaplan explained. “Not just that they have diabetes so put them on diabetes care plans, but understanding that they have diabetes and are at risk for a heart attack and have no caregivers at home so that primary care physicians can get patients to the programs they need. Versus, ‘Whoops, they are in the hospital, they have these three conditions, and refer them to these things post-discharge.’”
And technology plays an important role in the health system’s care coordination efforts.
“Ten years ago, the technology to do case management meant you had an EHR plus all of these third-party applications that made it difficult to look at data, you needed the ability to get into other systems to effectively manage those care transitions to another level of care,” said Susan Tolin, lead consultant at John Muir Health and manager at The Chartis Group’s informatics and technology practice. “So now we are looking at moving that all into the EHR so that everyone can see the same information and you are not duplicating tasks, eliminating a lot of phone calls. ‘I can see the information, I do not have to track that down.’ That helps a lot with saying, for example, here is what the RN case manager will support and what the support team will do.”
Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com
