March 1, 2017

6 Ways to Improve Population Health Management

How Cleveland Clinic ACO saved $34 million in Year 1


Affordable Care Act or not, value-based care and reimbursement is the future of U.S. medicine. Transitioning away from fee-for-service models could take years, but some medical practices — especially those in a Medicare Accountable Care Organization (ACO) — have gotten a head start by collaborating on population health management.


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“An ACO is really a training ground where we’re learning valuable lessons in how to provide healthcare rather than sick care,” says Nirav Vakharia, MD, Associate Chief Quality Officer at Cleveland Clinic and Vice Chairman of Cleveland Clinic’s Medicine Institute.

Cleveland Clinic’s Medicare ACO, begun in 2015, has learned quickly.

In its first year, it became one of the nation’s highest performing ACOs — the No. 1 first-year ACO, No. 6 overall. By connecting patients to medical homes and care teams, proactively managing their continuum of care (including at skilled nursing facilities) and establishing other value-based efforts, patients stayed out of hospitals and relied less on emergency care.

As a result, Cleveland Clinic’s ACO saved Medicare $33.9 million in 2015 (and received $16.6 million back in shared savings).

How did they do it? Dr. Vakharia credits these efforts:

  1. Know who your patients are. “We are becoming more heavily focused on attribution — making sure that if we are responsible for a patient, they are assigned to a primary care physician in our system and have a medical home,” says Dr. Vakharia. “Currently, at Cleveland Clinic, about half of our overall primary care population is attributed. That number is growing each year.”
  2. Establish a team-based care model. “Population health management takes a team,” he says. “It’s not just a doctor calling the shots, but doctors, nurses, care managers, pharmacists and social workers all collaborating.”

Everyone should be working at the top of their license, he adds, so everyone is contributing the most they can, most efficiently.

  1. Train caregivers to think “healthcare,” not “sick care.” “You can’t just go into the clinic and flip a switch and say, ‘Now your job is to prevent ER visits,’” he says. “It’s a long transition, and it involves everyone on the team.”

To ensure all team members know their roles and responsibilities, Cleveland Clinic is instituting a curriculum. The 12-week program will train all caregivers on principles of population health management and how to integrate all team members.

After completing the curriculum, teams will meet weekly to review patient panels and discuss initiatives such as building chronic disease management programs and forming “medical neighborhoods” of specialists.

  1. View patients holistically. Behavioral, social and functional factors also affect patient health — not just biomedical factors. In late 2016, Cleveland Clinic began including this additional data (contributed by the patient) in electronic medical records. Caregivers can see patients’ risk factors and strengths across domains.

Evaluating the whole patient enables caregivers to address all avenues (such as family support) and barriers (such as transportation challenges) to healthcare.

  1. Partner with the community. “If environment plays a major role in patient health, Cleveland Clinic wants to be present wherever patients are,” says Dr. Vakharia. “For example, we’ve begun putting clinics in schools to provide more community health services. We’ve begun offering free mammograms and smoking cessation classes at community centers.”

Community efforts are driven throughout Cleveland Clinic, including at local primary care practices, which build relationships with churches, schools, police departments and other facilities.

  1. Engage patients. Engaging patients when, where and how they want is a challenge for all providers, but it’s vital to the doctor-patient relationship, says Dr. Vakharia.

At Cleveland Clinic, patient access has improved with same-day appointments (1.3 million in 2016), walk-in Express Care locations, follow-up visits via videoconference, and a patient portal where patients can email their primary care physician, request prescription refills and schedule appointments. In 2016, nearly 2.2 million Cleveland Clinic patients had MyChart accounts.

“Changes to healthcare practice are inevitable, but they are not to be feared,” says Dr. Vakharia. “The new way of operating aligns better with the reasons most of us entered healthcare — to take care of people, not just see them in 20-minute increments.”

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