The mid-size: Northeast Georgia Diagnostic Clinic

By Marlene McIntyre, director of quality, risk & population health

Northeast Georgia Diagnostic Clinic, NGDC, is a provider of medical care and treatment in the Northeast Georgia area.

Since its humble beginning in 1953, the privately owned physician practice has grown into a multi-specialty practice of 36 physicians and 11 mid-level providers across seven specialties.

In addition to the primary location in Gainesville, Ga., which includes full-service radiology, lab, pharmacy, diabetes education, nutrition and physical therapy services, the practice also has additional offices in Braselton and Athens, Ga. One of NGDC's greatest advantages is the ability to offer a broad range of services under one roof – from primary care, to specialists and supportive therapy services.

NGDC's patient population is somewhat unusual in that it is roughly 60 percent Medicare fee-for-service, with the remaining patients being largely commercially insured. The practice is a National Committee for Quality Assurance-recognized Level 3 patient-centered medical home and has a robust care management program, which places a significant focus on managing care transitions post-hospitalization, chronic disease management, and the management of high-risk patients through shared savings programs and a community clinical integrated network.

It is critical for NGDC to be able to gather and review data from multiple venues on the healthcare continuum, and combine that data with its own health information management system, HIM,  in a timely fashion to gain a 360-degree view of patients' needs, identify care gaps and generally help them better self-manage their care.

With more than 50,000 patients in its population, NGDC care providers realized attempting to manage the needs of those patients manually would quickly overwhelm the practice's limited resources. Instead, the organization opted to implement a PHM platform that would help it build patient registries based on chronic conditions, identify care gaps, perform outreach, remind patients of their pending appointments, and otherwise assist in supporting quality and performance-improvement programs. The platform is also enabling technology for the HIM, bridging the gap between multiple patient systems to provide a single source of information about the care NGDC patients have received.

The practice's care management and PHM programs support three primary initiatives:

• The care management program helps ensure patients who are transitioning back home following ED visits or admissions to the hospital receive the follow-up care they need at NGDC. The platform automatically reviews data from the hospital systems to identify needs such as scheduling follow-up visits, performing post-discharge medication reconciliations and ensuring that complications and concerns are addressed quickly, before they lead to readmissions.
• Participation in the Centers for Medicare & Medicaid Services' chronic care management program, which is designed to help patients with two or more chronic conditions that put them at greater risk for complication or decline. The organization uses the PHM platform to risk-stratify patients, manage care coordinator workflow, and identify patients that are due for follow-up communication. The system also provides a comprehensive look at each patient including chronic condition needs, preventive care needs, care gaps and opportunities, medications, and appointments.  The PHM platform also provides the care coordination team with a quick and easy route to a full view of the patient, which they otherwise would have to gather from visiting numerous screens in two different systems. While the program pays $40.59 per patient per month for care coordination, it also benefits the group's overall population health program and allows it to engage with patients earlier and more frequently, tackling those patients that are often "below the waterline," before they become high-risk.  Without the automation and efficiency gained from the PHM platform, it would be impossible for the organization to manage the hundreds of patients it has enrolled. 
• The third is a standard care coordination category for patients in need who don't meet the criteria. This category includes high-risk and complex patients for which NGDC providers need additional support through the practice's care management team, as well as patients in shared-savings and clinically integrated network arrangements. As part of this program, NGDC is also able to review claims data from payers to help identify when gaps in care have been closed by another provider outside its network. Access to a community health exchange is also utilized to help ensure NGDC is aware of the full spectrum of care provided to their patients.   

With a comprehensive service line that encompasses primary care and endocrinology, as well as diabetes education and nutrition, care for patients with diabetes is a major area of focus for NGDC. Through the PHM platform, care coordinators can look at the practice's entire diabetic population on one screen, and in just a couple of clicks they can risk-stratify that data by A1c value, number of care opportunities, or other metrics that allow them to quickly and easily identify outliers, and then engage with those patients. While control of the patient's diabetes may be the initial prompt to engage with the patient, the overall objective is one that focuses on the overall health of each patient.

As NGDC approaches its one-year anniversary on the PHM platform, and it recorded three top successes:

• More than 29,000 patients were identified to have at least one care gap
• More than 15,000 patients were proactively contacted via outreach related to their care opportunities
• Successful closing of care gaps, with improvements particularly in chronic condition follow-up care, wellness visits, preventive screenings and vaccinations

How a small organization uses population health initiatives: Next page