Sixteen years ago, when I first started working in population health, it seemed unlikely that the main-stream healthcare industry would embrace the medical home model and population health management. Oh, how times have changed!

Bon Secours Medical Group has

dedicated itself to implementing

a sustainable care delivery model

aligned with healthcare reform.

The Age of Healthcare Reform is upon us. With the advent of the Affordable Care Act, value-based purchasing, and opportunities like the Medicare Shared Savings Program (MSSP), embracing value-based care makes strong financial sense for hospitals and group practices. My organization—Bon Secours Medical Group (BSMG)—has dedicated itself to implementing a sustainable care delivery model aligned with healthcare reform. And we’re having real success.

BSMG is a multispecialty group practice with more than 100 locations in the Richmond, Virginia area. We serve more than 500,000 patients each year. Our transformation into an organization that thrives in a value-based care environment is, of course, ongoing. What follows is an overview of strategic steps we have taken to make a smooth, sustainable, and successful transition to population health management.

A Leap of FaithExecutive leadership at BSMG is 100 percent com-

mitted to population health management. Long before I joined the team, they committed to a value-based care delivery model—even though they hadn’t established a proven payment model for the transition to value-based care. They simply knew it was the right thing to do for the health of their patients and for the financial health of the industry as a whole.

Without payer backing, they took a leap of faith and launched the project.

We began implementing the best technology we could find for population health management, and we began making necessary workflow adjustments to sup-port large patient panels.

Because 45 percent of our providers are primary care providers (PCPs), we launched a patient-centered medical home (PCMH) initiative—the Advanced Medical Home Project—as our foundation for driving value-based care. The project began as a pilot in June 2010 and was aided by the 2012 National Committee on Quality Assurance (NCQA) decision to provide PCMH “auto-credit” for users of our population health management software (Phytel), which automates many PCMH requirements. Since that time, 14 of our practices have earned the highest level of NCQA recognition as patient-centered medical homes (Level 3), and that number will continue to grow.

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Thriving in Changing TimesA Guide for the Age of Healthcare Reform

By RoBeRt J. FoRtini, PnP

March2014_mech.indd 46 3/10/14 9:14 PM

We Built It; They CameWe would have loved to have payer involvement

in our PCMH initiative from the outset. Instead, we invested upfront in population health processes and technology so that we could demonstrate results to our payers. We hoped they would come to us if we built a viable program. They did.

The first payer to back us was Medicare. We were selected as an early participant in MSSP. Then, we were able to sign value-based contracts with CIGNA and Anthem. CIGNA currently gives us a per-member per-month (PMPM) adjustment for care coordination. Anthem—our biggest payer—pays us a care coordina-tion fee but will change to PMPM in the coming year. Other commercial payers are lined up to sign value-based contracts with us.

Clearly, our return on investment is flowing in. Securing payer involvement has given us a financial mechanism to sustain and scale our medical home initiative.

One of the main goals of our Advanced Medical Home Project is to make it possible for our PCPs to double the size of their patient panel without overbur-dening themselves or sacrificing quality of care. How is that possible? By creating care teams in which each member of the team operates at the maximum level of his or her license and qualifications.

To re-engineer clinical practice and care manage-ment processes, we created high-performance care teams led by physicians. In this team model, physicians share responsibility for patient care with other mem-bers of the team, which allows them to focus on those patients who truly require physician attention.

Embedded Nurse NavigatorsWe decided to embed care managers into the

primary care team. These embedded, professional case managers—called nurse navigators—are RNs who are either board-certified case managers or actively working toward certification. We now have 42 nurse navigators managing care across 25 locations, and we are actively recruiting 30 more this year.

Each nurse navigator is assigned a panel of approxi-mately 150 high-risk patients. The navigator cultivates a personal relationship with these patients, usually through repeated phone contacts. Although most outreach is done by phone, navigators have the skill to assess which patients require face-to-face intervention. Because they are embedded in the practice, they can spend time with these patients doing assessments, care planning, and edu-cation. They are able to meet the patient’s needs while freeing up physicians to see other patients.

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This ability to take clinical tasks off the physician’s plate is what makes it possible for our practices to increase the size of their patient panels while provid-ing high-quality care. But the concept of the care team can be difficult for some physicians because they see themselves as the providers and the rest of the team as support staff. To help physicians embrace the care team and delegate patient-care tasks, we placed a lot of emphasis on physician education. We also allow physicians to adjust some of the standardized care-team protocols to fit the needs of their practice. This fosters ownership of the process and assures physicians that they remain in control.

High Touch for High RiskGetting the right care teams in place is one part

of our population health management solution. The other critical aspect is implementing health information technology that empowers the care team to efficiently manage their populations.

High-touch approaches are required for the high-est-risk patients, who constitute from 2 to 5 percent of a typical patient population. However, it is unrealistic for office staff and care managers to maintain personal contact with the thousands of people who have modifi-able risk factors in a medium-sized practice. Com-pounding the problem, nearly 60 percent of the highest risk patients in any given year were not high-risk the previous year. Their conditions worsened out of sight of their physicians, so they fell below the waterline.

At BSMG, we needed automation tools to predict and identify these below-the-waterline patients and uncover the gaps in their care. And we needed technol-ogy that would help us prioritize and automate the right care interventions so we could scale our program to a population level.

Leveraging our initial technology investment with Epic’s ambulatory electronic health records (EHR) provided us a solid foundation for documenting care and accessing health records. With our health records digitized and a central database of patient information, we turned our attention to a patient-centered registry for population health management.

After developing the registry, one of our first con-crete objectives was to help the nurse navigators pre-vent 30-day readmissions. The registry could identify high-risk and high-utilization patients based on number of medications and frequent visits to the emergency department.

Nurse navigators use the system to identify patients discharged from the ER or an inpatient stay. The system links each patient to a PCP and identifies

those at high risk for readmission. Nurse navigators can then run the discharge registry for the physicians in their practice, take those names, and make phone contact with the patient within 24–72 hours. The pro-cess reinforces discharge instructions with the patient, ensures that all medications are reconciled, and then schedules an appointment at the PCP’s office within 5–10 days of discharge.

We have been very pleased with our results. Through our discharge registry and the intervention of nurse navigators, the 30-day readmission rate for patients in PCMH has been under 2 percent for the last two years.

Juggling Act SolutionOur homegrown registry has clearly driven some

significant success for our PCMH initiative. But we have also come to recognize that it simply isn’t flexible enough to scale up to what we need. Because we have a Medicare accountable care organization (ACO) and contracts with multiple commercial payers, we need a solution that can manage all these contracts at the same time.

As each payer launches a unique quality-improve-ment initiative with us, they require us to track and measure differing quality measures. We have to align with multiple payers’ quality definitions and denomina-tors—while performing analytics and predictive model-ing across multiple clinical conditions. We have begun to adopt advanced elements of the Phytel platform to address this need for a flexible registry solution.

Phytel has integrated with our source systems to aggregate our data into a population-wide registry that allows us to implement multiple quality-improvement programs simultaneously. The registry stratifies the population by risk—providing a total population view while enabling each care team to drill down to the data they need on cohorts and individual patients.

We are currently using the Phytel registry to identify gaps in care and perform automated patient outreach. We will be expanding the implementation to include functionality for preventing readmissions and analytics to measure the effectiveness of all of our improvement efforts. The readmissions solution will automate much of the resource-intensive work involved in following up with discharged patients to ensure they adhere to their therapy plan and get the right care. Instead of a phone call from a nurse navigator, patients will receive an automated call asking them to complete a short assessment. They are asked how they are feeling and whether they understand their discharge instruc-tions, whether they have questions regarding their

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medications, and whether they have contacted their primary care doctor. If people indicate that they’d like the hospital to contact them, the system will escalate them to a nurse navigator for immediate contact.

Active Patient EngagementOur efforts to improve population health can’t

fully succeed without involving our patients. Our PCMH initiative incorporates strategies for engaging patients in their care, including programs to automate outreach to large patient populations. We use the Phytel solution for this outreach. For example, our care teams use the system to search for diabetic patients who have not had a diabetes-related visit in the previous six months and do not have a visit scheduled in the next two months. The system then notifies these patients of the recommended care through automated outbound messaging. And it can then track patient response and monitor whether they come in for the necessary ap-pointment—background work that is one example of why our system receives NCQA autocredit.

Another strategy we’ve pursued for patient engage-ment is activating patients on Epic’s MyChart personal health record (PHR). The PHR allows patients to view clinical results and communicate with the care team. We first worked to gain physician consensus on PHR policies: physicians agreed to allow automatic release of normal results to the PHR, but we hold abnormal results for 24 hours to allow the care team to contact the patient. We rely on physicians and staff to get patients active on MyChart, helping them sign up on the spot in the exam room. We have conducted campaigns to pro-mote MyChart activation among practice staff, including challenges and competitions that have proved effective.

Strategy: Dig In, Get StartedTransitioning to population health management

may seem daunting. We discovered that just digging in and getting started was the best approach. Our success is built on:

■■ Committing to the transition as an organization

■■ Attracting payer backing for a sustainable payment model

■■ Creating efficient care teams led by physicians

■■ Implementing the right technologies

With this infrastructure in place—and adapting as our needs adapt—we are confident that we will succeed in the new healthcare environment.

Robert J. Fortini, PNP, is vice president and chief clini-cal officer at Bon Secours Medical Group.

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