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St. Luke's Early Learning When it Comes to Population Health

By Dr. David C. Pate, News and Community
May 30, 2013

Editor's note: The following report first appeared in the mid-May "Gary's Take" newsletter from St. Luke's Health System Chief Operating Officer Gary Fletcher for St. Luke's employees. 

More and more across St. Luke’s Health System, people are understanding what we are trying to do in focusing on the Triple Aim of better health, better care, and lower costs.

From an operations standpoint, the Triple Aim can be viewed very broadly as wellness promotion, fitness, screenings, education, and prevention (better health), coordinated  care (better care), and evidence-based care provided efficiently in the lowest-cost setting (lower cost). Our programs and services obviously overlap, and we’re finding that to improve in one area often means improvement in another, or even both, of the other two.

We’re starting to focus more on our population health management, care coordination services, management of care transitions, and partnerships with insurers and other post-acute care providers (for example, rehab, skilled nursing facilities, and home health). As we move from a fee-for-service health care model to one based on value, we’re learning a great deal about how to build successful population health programs. Below you’ll find updates on some of these efforts.

CoPartner

Our CoPartner program, which concentrates on people with more complicated health needs, has taught us the importance of individualized care plans and behavioral health screening, and how much attention will need to be paid to factors other than the diagnosed conditions.

Of approximately 100 early CoPartner participants, nearly 45 percent have had undiagnosed or inadequately treated depression and other similar diagnoses. And we know that depression and undiagnosed disorders make treatment, medication adherence, and other solutions much less successful.

Other Learning

We’ve also seen how fragmented our programs have been. Our programs might be good, and we have good intentions, but many have operated in silos, thereby exacerbating a problem we are trying to resolve. 

We noted the potential of patients being visited at home by four or five St. Luke’s employees after hospital discharge, all from different programs, resulting in confusing and inconsistent information and advice. 

We are also seeing how critical physician engagement and advocacy are, and what it takes to ensure that engagement and alignment.

Physicians won’t advocate for programs, no matter how well intentioned, if enrollment, billing, and office procedures are made more complicated by the programs. We will need to standardize and simplify processes so that front-line physicians  and patients will see improved efficiency of work flows and quality of care.

And that’s just the early learning, and only from one of several population management pilots and projects we are involved in!

Transitions of Care

We are engaged in many population management efforts that focus on care management, preventing hospital readmissions, and coordinating care. And while many of the efforts have started in, or centered around, our hospitals, we expect that more programs will move to the outpatient setting over time.

The Transitions of Care project in the Treasure Valley and like efforts in the Magic Valley, Wood River, and McCall, along with newer efforts being built around care coordination, are tackling medication reconciliation, standardization of discharge processes, communication with primary care and community providers, communication with post-acute care facilities, and care transitions.

Working on all fronts is challenging, and each area carries its own set of complexities.

Take medication reconciliation, for example; there may not be a shared understanding of what “medication reconciliation” means, or how thoroughly the area is explored. Some feel that checking a box counts as medication reconciliation, while our home health care nurses know better! The medications a patient is taking need to be seen at every encounter.

Next Steps

Great ideas are being identified, assessed, and measured across the System. So, for example, a pilot project employing a pharmacy technician in the ED has begun, and use of a medication teaching guide, started in the Boise hospital, is being expanded.

Many of these pilot projects started in the fall, and we are now assessing for their potential as best practices. We’re also building a structure for care management, compiling data, and putting it in place for use.

About 26,000 people are or will become part of these early population management efforts this year, and we expect about 50,000 people will be receiving our population management program services by the end of 2014.

Some of the programs we are testing and that we envision are very different than those traditionally administered by St. Luke’s Health System and other care delivery organizations. As our CoPartner efforts have shown, an increasing emphasis will need to be placed on what isn’t known about a patient’s condition, and finding out what needs to be in place for care solutions to work.

It’s an exciting time to be part of St. Luke’s Health System, and I appreciate all the efforts everyone is making as we work to achieve our Triple Aim!

About The Author

David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.