The Healthy Outcomes Solution for Population Health Management

Patient Activate, the population health management solution in InteliChart's Healthy Outcomes platform, was a must-see for health centers attending the California Primary Care Association (CPCA) 2018 Annual Conference.

Representing more than 1,300 not-for-profit Community Health Centers and Regional Clinic Associations, CPCA is a key player in the healthcare delivery system. The Association leads and positions community clinics, health centers, and networks through advocacy, education and services with a focus on improving the health status of their communities, particularly low-income, uninsured and underserved Californians, who might otherwise not have access to health care.

Considering CPCA’s membership of urban and rural clinics, federally funded clinics and clinics dedicated to special needs and special populations, research conducted by the Peterson-Kaiser Health System Tracker is germane. The Peterson-Kaiser Health System Tracker provides up-to-date information on trends, drivers and issues that impact the performance of the healthcare system. It also illustrates how the U.S. is performing relative to other countries.

One particular study - Looking at Social Determinants of Health in the U.S. and Comparable Countries - found income can significantly influence health outcomes and that people who have lower incomes are less likely than those with higher incomes to report being in good health. The study further concluded there is a growing disparity in the life expectancies of low- and high-income Americans.

Also included in the study was data on behavior and lifestyle-related social determinants of health, citing that the U.S. has the highest prevalence of obesity and insufficient physical activity among adults compared to other high-income countries. Furthermore, the World Health Organization quantified the effect of environmental factors, such as pollution, occupational risks, agricultural methods, climate change, and food contamination and taken together, these factors present a higher burden of disease in the U.S. than in comparable countries.¹

Add to the mix that 5% of the population – those with two or more chronic conditions - account for 45% of all healthcare spending,² and it’s clear that clinics face an undeniable challenge in keeping their patients healthy.

Enter: Population Health Management Technology

Between social determinants, poly-chronic patients, and minimal resources, how can a clinic effectively manage population health while also keeping an eye on value-based care reimbursement? With technology that streamlines data, conducts analysis, automates outreach, elevates outcomes, and improves MIPS performance.

Clinical and claims data aggregated from a health center’s electronic health record (EHR) are the foundation of these technologies. From this baseline, providers can incorporate other crucial data into their analysis, such as these social determinants:

• Physical environment. Air and water quality; housing type, access to transportation and proximity to grocery stores.
• Behavioral. Diet, exercise, tobacco- and drug-use; stress, adherence history information, and metrics on estimated likelihood to modify behavior.
• Social. Education level, literacy, employment, income, financial history, neighborhood, and highly granular data such as the distance away from the closest relatives.

Armed with these rich datasets, clinics can stratify patients into risk categories, such as chronic-condition populations, and identify highest-risk patients who need interventions. Population health management technology reduces the labor-intensive data searching and patient communication with lower-risk patients so care managers can focus more of their limited time on higher-risk patients to help them overcome care plan adherence obstacles.

It’s also important to note that a providers’ ability to manage populations across all risk profiles is key to success with MIPS or any value-based care payment program. After all, today’s moderate-risk patient can be tomorrow’s high-risk patient.

Outreach Campaigns Build Patient Engagement

A clinic tracking diabetic patients, for example, can establish rules within the population health management platform to automatically contact patients through multiple modes such as phone, text, postal letter, or through a patient portal. The notifications send an alert when patients should take a certain medication, have not scheduled a maintenance appointment, or forget to fulfill self-management tasks such as recording home blood pressure readings or glucose monitoring.

Multiple campaigns can be combined for a more comprehensive automated analysis and outreach effort. Regardless, organizations must only create the campaigns one time and the platform will automatically search the updated patient populations for at-risk patients.

As a result of automated interventions, patients can be contacted using their preferred communication methods seven to 10 additional times in a month without giving more work to already overburdened clinic staff. A 2016 study of text message medication reminders found it doubled the likelihood of adherence to regimens, affirming the efficacy of technology-assisted interventions. Plus, consistent and relevant outreach and communication yield strong engagement from patients who feel more connected to providers demonstrating concern about their health throughout the year. 

Healthy Outcomes: The Platform for Engagement to Outcomes

Patient Activate – one solution in InteliChart’s Healthy Outcomes suite - empowers clinics to tackle population health management head-on. This powerful solution acquires and aggregates patient data from a single source or multiple systems using one API platform. The tool establishes intervention goals, creates automated campaigns, and helps attain outcome goals.

Additional solutions in the Healthy Outcomes suite include:

• Patient Portal - 2015 MU3 Certified, satisfies MIPS requirements, integrates seamlessly with acute and ambulatory EHRs, and aggregates data into the Healthy Outcome's clinical registry so that patients can see all of their data in a single portal.
• Patient Survey - automates delivery for patient satisfaction surveys and patient-reported outcomes.
• Patient Notify - eliminates workflow inefficiencies by automating patient communications.
• Patient Intake - creates a consistent intake process for patients that increases portal adoption and streamlines the check-in workflow.

Healthy Outcomes helps health centers:

• Maximize reimbursement
• Reduce no-shows
• Streamline staff efficiency
• Achieve healthier outcomes

With Healthy Outcomes, your organization works in harmony with one vendor for all your solutions, as opposed to the inefficiency of working with numerous vendors and applications that don’t mesh. Our dedicated training and support teams further facilitate seamless implementation.

See Healthy Outcomes at CPCA’s Annual Conference, Booth #431

We are excited to showcase the power of our Healthy Outcomes platform at CPCA’s Annual Conference and welcome providers to visit our booth to see first-hand the advantage of working with a single vendor for multiple solutions, the ease of one integration, and the efficiency of data from all sources syncing back to a clinic’s EHR. We’ll demonstrate how to automate population health management as it relates to MIPS performance, enabling your organization to perform at an optimal level for your patient engagement and quality performance needs.

¹ https://www.healthsystemtracker.org/brief/a-comparison-of-social-determinants-in-the-u-s-and-comparable-countries/#item-start

² https://www.oliverwyman.com/our-expertise/insights/2012/nov/the-volume-to-value-revolution.html