Practicing Award-Winning Population Health

Practicing Award-Winning Population Health

Medical center program offers strategies for others assuming clinical, financial risk for patient base

Hennepin County Medical Center reduced emergency department visits by 37 percent and inpatient stays by 25 percent within a year of opening its multidisciplinary, team-based Coordinated Care Center aimed at high-usage patients. The 426-bed Minneapolis-based medical center says it’s getting a more than 4-to-1 return on what it’s spending per patient on the effort, which began in the fall of 2010.

Those promising results, which demonstrate that better care and better financial health go hand-in-hand, can be replicated at other hospitals and health systems that have assumed the clinical and financial risk of providing care for a dedicated patient population.

For its efforts in improving both care and financial performance—and for user satisfaction scores that are “through the roof”—HCMC recently earned the 2013 Gage Award for Improving Population Health from the National Association of Public Hospitals, now known as America’s Essential Hospitals.

“The ground-breaking work underway by McKesson customer Hennepin County Medical Center is what I believe our next-generation hospitals will emulate in the years to come,” says Scott Miller, senior vice president of McKesson Health Systems. “It has been a privilege to observe the best practices and integral role that the HCMC head of pharmacy, Bruce Thompson, has played in the coordination of care.”

Creating Super-Utilizer Model

HCMC decided to open the Coordinated Care Center after its internal studies showed that 3 percent of its patients were responsible for about half of its total costs. To ensure a focus on those high-cost patients, the care center has admitted only patients who had been hospitalized at least three times in the previous 12 months.

“We’ve segmented and targeted a super-utilizer model in our hospital,” says Paul Johnson, M.D., medical director of the Coordinated Care Center. “We’re selecting a population that is using a lot of healthcare services, and the system is failing to meet their needs for a whole variety of reasons. When you look at the high-utilizing population in our hospital, what is driving that is not complicated medical problems—it’s social problems.”

Through its analysis, HCMC realized that drug use, homelessness, mental health issues and cognitive impairments are “the kinds of things that fuel super-use,” he says, so it structured the Coordinated Care Center around multidisciplinary teams that include not only doctors but nurse care coordinators, social workers, behavioral health workers and drug abuse counselors who “work together on the underlying problems.”

Johnson advises his colleagues around the country, some of whom are working on similar efforts, to take the same approach, which he believes has been key to HCMC’s success.

“In every payment system out there, a few patients are spending an inordinate amount of money,” he says. “They’re not trying to spend too much money. It’s not what they want to do. There’s just not a system helping them not to do that. The folly in our care system is that we try to saddle providers with patients who have such complex social and behavioral needs, and we don’t give them any tools to do the job.”

When these “super-utilizers” arrive at HCMC, they’re seen the same day, not scheduled for some future appointment, Johnson says. “We will invite you in and address your issues,” he says. “We will try to take those things on. But our patients still do come in and out of the hospital more than we’d like.”

Community Support Following Discharge

To help reduce those visits, the Coordinated Care Center follows up within 72 hours of discharge to ensure, for example, proper adherence to medication regimen, a process that can include appointments with clinical pharmacists once every week or two. Specialists closely track behavioral and social determinants of health, and the center’s specialists also have built relationships in the community to further address those types of issues.

“We make sure the [homeless] shelter coordinators know our nurses,” Johnson says. “Our social workers know the community’s resources well. They refer patients. We have relationships in both directions. Cultivating those community resources has been a critical thing we’ve done.”

In addition to measuring global quality metrics like the aforementioned reductions in emergency room and inpatient stays, HCMC has begun to hone in on more specific issues like high blood pressure among the center’s patient population, although the aggregate results over time on those more specific measures are still to come.

“We think we’ve done those things along the way,” he says. “Nothing’s more dissatisfying than being hospitalized. Given that we’re reducing [hospitalization], we’re improving everybody’s quality of care.”

Johnson says an internal analysis shows HCMC is saving about $25,000 per year on each of its patients on costs not incurred because their chronic conditions are being adequately managed—more than four times the $6,000 per patient it spends on the program. The current caseload sits at 225, he says, while probably closer to 300 total have used the center since its inception.

“Patients rarely choose to leave our clinic because they’re so happy with the services,” he says. “Voluntary departure is almost unheard of.”