The Patient Protection and Affordability Act of 2010 put forth a directive stating that providers should become more responsible for the quality of care they provide and actively participate in lowering the cost of care. While often referred to as "healthcare reform," the focus has been on "payment reform," with an emphasis on a new Medical Home Model that involves risk-sharing and bundled payments. The healthcare reform law instructs the Centers for Medicare and Medicaid Services (CMS) to create a shared-cost savings program for accountable care organizations (ACOs), which are groups of hospitals and doctors working together to reduce the cost and raise the quality of care.
Like the Health Care Act of the Clinton administration, the goals of improving quality and decreasing cost appear similar. Adoption of the legislative priorities was resisted across the nation, except for areas of the country that embraced a payment model of capitation. Capitation models paid a dollar amount per patient to the hospitals, providers or organizations, and in turn, those organizations were responsible for managing the care and risk, and dividing the payment between the providers. Except for organizations where there were an insurance company and rich analytics, most organizations failed to be successful under this model. The data on the risk of the populations, the utilization of the populations, and the outcomes of the care were not easily accessible.
Today's scenario is different. Now with a parallel drive to electronic medical record (EMR) adoption, Meaningful Use standards, and access to big data, the information needed to understand the behavioral characteristics of a given population are available to nearly all medical organizations.
Clinical data, risk stratification and cost can be more readily accessed at the point of service to enhance the providers' decision making. It now makes sense for organizations to pursue at-risk populations, a fundamental shift from providing care for the sick or injured to prevention, wellness, patient self-management and earlier care interventions. Payment models based upon assuming risk for quality, cost and outcomes now have the data and analytics they need to fulfill goals of healthcare reform.
Approach to a Population
Population Health Management is focused on keeping communities as healthy as possible. This continuous process includes prevention, early screening, timely diagnoses, appropriate use of resources, evidence-based care, chronic care management and palliative care. Anticipating the needs of the population, and of the individual, is critical to building the right infrastructure.
Population health can be based upon a variety of approaches to defining the population. A population can be a geographic region, or a group of patients within a particular payer group, or a subset of patients who share a similar clinical condition.
In 2010-2013, Carolinas HealthCare System identified a pilot population of patients with chronic obstructive pulmonary disease (COPD) and used this group to better understand the requirement of building the capabilities needed for a population health approach. Funded in part by a Beacon Community Grant, the project looked at ways in which the system could identify, screen and treat a group of patients with this serious chronic condition.1
Patients with COPD are an especially high-risk chronic population. In fact, COPD is the third highest cause of death in the country. Every year, 800,000 patients are admitted for a COPD exacerbation, and one out of five hospitalizations in people over the age of 40 carries a diagnosis of COPD.2 The COPD population in particular requires a cross continuum approach to continuous care, rather than episodic care in the emergency departments (ED) and hospitals.
Carolinas HealthCare System took a segment of its delivery system and tried to identify every patient with COPD, whether the patient presented in the ED, primary care office or hospital. Community events at fairs and parks were used to increase awareness, and screen and identify new patients.
A common approach to care was developed by a multi-disciplinary group of providers. Respiratory therapists (RTs) and pulmonologists took an active role in the care design. Family physicians, palliative care physicians, emergency medicine physicians and hospitalists were also included. Because of the availability of the GOLD Guidelines, reaching agreement on the approach to care was streamlined.3 The GOLD Guidelines encourage early diagnosis and evidence-based management. Embedding the GOLD Guidelines into practice across a healthcare delivery system can be a challenge, but one that ensures clinically appropriate care for the patients at every point in the continuum.
Carolinas HealthCare System proactively found patients through the use of a simple five-question validated risk screener from the COPD Foundation.4 Every patient completed the screener in their primary care office visit and at community events, like fairs and senior centers, where the outreach teams focused on awareness and education. The GOLD Guidelines focused on respiratory testing to confirm a COPD diagnosis, and the team of RTs and case managers performed mobile spirometry testing at these community events and companies, as well.
Patients at the Center of Care
Patient education is critical for improving quality of life and avoiding exacerbations. RTs and care managers help them understand their disease, medication administration, symptom management and critical moments when to call for help. They then follow up in person or by telephone to discuss the patient's progress. In this new model, patients become partners with their healthcare providers and play a greater role in shared decisions. They become empowered and engaged in their care -- on their terms.
Community resources play a key role. For example, the COPD Foundation has a platform to build the patient community utilizing: social media like Facebook and blogs; reaching out to the COPD population with peer-to-peer coaching and education; digest magazines; and patients who actively participate on advisory boards.
Group visits to physicians or RTs can also create a safe learning and sharing environment. This discussion often occurs during pulmonary rehabilitation visits where natural friendships and trusted relationships with professionals lead to a common dialogue with patients and providers. Communicating with others living with COPD encourages patients to continue in their treatment and physical activity, as well as share what they've learned.
One of the critical tools for proactively managing population health and identifying at-risk patients is the patient registry. The registry is a master list that identifies patients every time they have an encounter, and their care is measured against the Gold Guidelines in a check and balance process-identifying potential interventions. The list ensures their required, medications, labs, pulmonary testing, and preventive services are kept up to date. The registry is constantly updated by the EMR with new entrants in the ED, on admission, urgent care and every site of service. At some point, registries should be able to generate reminders to patients via text or patient portals to keep them empowered to stay within the guidelines.
Unfortunately, data suggests that barely 50-60 percent of COPD patients receive care according to existing guidelines. A key issue preventing widespread guideline adherence is the length and complexity of existing guidelines. To address this issue, the COPD Foundation developed a simplified Pocket Consultant Guide. Over the last 10 years, the Guide has been updated eight times, and almost 500,000 have been distributed to providers around the country at no charge. The latest version suggests that care be aimed at seven severity domains: spirometry, symptoms, exacerbations, oxygen requirements, presence of emphysema, chronic bronchitis, and comorbidities.
The Guide provides guidance on how to use therapeutic options. A free interactive app is available free in the iTunes app store, searchable by typing in "COPD Foundation."
The goals of effective COPD management are to prevent disease progression, relieve symptoms, improve exercise tolerance, prevent and treat complications/exacerbations and improve the quality of life. The extent to which these goals can be realized varies with each individual, and some treatments will produce benefits in more than one area.
To provide better care across the healthcare delivery system requires a threefold effort, which consists of embedding the GOLD Guidelines or the COPD Foundation's Pocket Consultant Guide into practice, utilizing a multi-disciplinary group of providers, and providing access to education and community outreach programs for individuals living with COPD.
In the age of healthcare reform, better care management must be designed to reduce hospitalization -- a key cost driver. Preventing exacerbations in COPD cases is one of the best ways to avoid hospitalization. The challenge going forward will be to develop care strategies that are ongoing for the long-term welfare of the patient.
Deb McGowan, senior director of Health Outcomes, COPD Foundation, has been a director of Clinical Case Management for over 30 years, working with patients as an advocate, and coordinating care in all healthcare settings: physician's office, hospital and home. She has demonstrated expertise in developing and managing innovative programs and medical management projects that improve the quality of care and delivery of services.
Dr. Wright, vice president, Innovation, Carolinas HealthCare System, is responsible for leading the advancement of innovation initiatives throughout Carolinas HealthCare System (CHS). Her focus is on working with teams to raise the bar for improvement in new clinical strategies, novel medical technologies, new business development, innovation design, and the spread of innovation across the system.
- The White House. Vice President Biden, HHS Secretary Sebelius announce selection of 15 Health IT Pilot Communities through Recovery Act Beacon Community Program. Available at: www.whitehouse.gov.
- HCup. Overview of hospitalizations among patients with COPD. Available at: www.hcup-us.ahrq.gov/reports/statbriefs/sb106.jsp.
- GOLD. Documents and resources. Available at: www.goldcopd.org/guidelines-resources.html.
- Drive4COPD. COPD Risk Screener. Available at: www.drive4copd.org/AreYouAtRisk/TaketheScreener.aspx.