CHIO shares secrets to sustainable population health

LAS VEGAS – "I could ask the audience what population health is, and I would probably get 100 different answers," said Terri H. Steinberg, chief health information officer and VP of population health informatics at Delaware's Christiana Care Health System at HIMSS18 on Tuesday. "And every single vendor on the show floor thinks they know how to define population health."

The reality is that "EMR vendors and other technology vendors all approach population from their own view," she said. "If you're Cerner or Epic, you're good at hospital EMRs and ambulatory EMRs, and you're going to expand from that. If you're Medecision or another population health vendor, you're going to expand into the walls of the hospitals and doctor's office from your own perspective. But the bottom line is it doesn't really matter – because you have to manage the population."

Steinberg speaks from experience. In just a few years, she helped lead Christiana Care from a fee-for-service holdout to a successful and sustainable model of value-based care management with nearly 200,000 members.

"In 2015, Christiana Care was one of the last bastions of fee-for-service medicine," she said. "We had a single large payer and we both sort of made the rules together."

But a Center for Medicare and Medicaid Innovation grant to implement a comprehensive care management program and an analytics-based IT platform helped changed its ways of thinking.

Along the way, "we realized that we were very happy to deliver services for which you can't drop a bill," said Steinberg. "Social work services and pharmacy services and other things that really move the needle but you can't deliver in a fee for service world.

So Christiana Care execs "approached the payer and said, 'We want risk. We want as much risk as you can throw at us.' And so our risk-based model was born."

Three years ago, the health system launched Carelink CareNow, a wholly-owned subsidiary that essentially operates as a care management company. It has contracts including ACO, direct to employer and payer partnerships, and comprise some 180,000 patients in the region.

Over recent years, the system has learned some valuable lessons about what it takes to succeed with population health, said Steinberg.

For one, "we manage all of our members all of the time," she said. "We rely on the technology to really bring to the attention of care managers things that are actionable. So the notion of a single panel or patients or a specific ratio is really almost an anachronism in the Carelink world."

And contrary to some folks' unfounded fears that accountable care means rationed care, "we've discovered that when you make your care levels actionable based on data, some people get a lot more than they ever thought they needed," said Steinberg. "Because the care comes to them. There's outreach to the member. Some people get more, some people get less. It's based on algorithms."

A critical component of evidence-based care delivery, she added, is to abide by a simple rule: "Don't do things that you can't measure. Because they're probably not important. And if they're important, you probably should be measuring them."

To be successful with pop health, you have to segment the population – whether that population is diabetics or NICU babies, said Steinberg. It's a complex process, and heavily dependent on clean data, sound processes and robust analytics.

But once that's done, the recipe for customized interventions for "right-sized care" essentially has just three ingredients, she said: Technology (for data integration and real-time triggers); care coordination ("the glue between doctor's visits – probably more important than the visits themselves"); and analytics ("to prospectively assess your risk and drive care to the right direction, you need to monitor how you're doing and feed that back to your organization and the providers").

All easier said than done, of course. But when tackled in earnest, such process changes can pay big dividends. Christiana Care has managed to gain improved utilization measures, reduced readmissions, substantial cost savings and (not insignificantly) increased provider and patient satisfaction.

Among the notable stats: It's seen a 30.4 percent reduction in the 90-day readmission rates for patients with total hip or total knee replacement; a 13.9 percent reduction in the 90-day readmission rates for congestive heart failure patients and an 11.8 percent increase in CHF patients being discharged to home with self-care or home health care.