HealthEast s Twist on Medical Homes Demonstrates Broad Range of Successes

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1 HealthEast s Twist on Medical Homes Demonstrates Broad Range of Successes The HealthEast Care System was created in 1986 with the merger of five health care organizations. Today HealthEast is the largest health care provider in the East Metro area of Minnesota s Twin Cities. In addition to four hospitals, HealthEast runs 14 primary care clinics, a variety of specialty care clinics, outpatient services, home and hospice care, medical transportation, and other hospital-based services. HealthEast declares that Our mission is high-quality, compassionate, cost-effective health care for the communities we serve. In 2008, Minnesota passed its Vision for a Better State of Health, a health reform law that included a provision for the establishment of what it called Health Care Homes (HCHs). An HCH, also known as a medical home, is an approach to health care in which primary care providers, families and patients work in partnership to improve health outcomes and quality of life. Coordination of care is a hallmark of the medical home. 1 HealthEast initiated a pilot HCH program in 2010 after recognizing the importance of finding new ways to engage patients to ensure they don t get lost in the overall health care system. By 2012, 100 percent of HealthEast s ambulatory clinics were certified throughout the state as HCHs. It is critical to keep track of who the patients are and where they are at with their health. We ve started analyzing at a basic level, looking at utilization trends both through emergency room use and hospital admissions. Julie Leibel, HealthEast Population Health Analytics team member One s Population Analytics module aggregates and normalizes EMR, practice management and claims data for analysis. HealthEast utilizes the Population Analytics database, intuitive analytics and libraries of standard and custom reports via secure web to (1) identify high-risk patients for HCH programs through predictive analytics; and (2) track clinical and financial outcomes over time. Page 1

2 Finding the Community Needs Since HealthEast s HCH program inception, the organization has demonstrated significant successes ranging from improved clinical outcomes to increased patient engagement and overall satisfaction. HealthEast attributes a portion of the system s results to the unique way they have tailored the care coordinator role. HealthEast utilizes Certified Community Health Workers, titled Care Guides, non-clinical individuals with a specific skill set focused around the needs of a particular community, to get at the heart of community needs. The Care Guides work side-by-side with primary care providers, registered nurses, licensed social workers and financial resource professionals. The collaboration and support received from all the members of the care team is a critical component to the success of the Care Guide role. Before hiring a Care Guide, the HCH leadership looks to the clinic to figure out the community needs, demographics and gaps in resources. Jessica Cunningham, Manager of Ambulatory Services and Supervisor of the HCH initiative, states, For example, our Rice Street Clinic has an extremely large Hmong population. We need a Care Guide fluent in the language with a cultural understanding for the internal drivers of the community. The Care Guides at some of our other clinics need to be more focused around nutrition and health coaching. She explains, We are trying to build a partnership with the patients. We start every care plan with what we call the I statement. This is where the patient says, I want to lower my A1C or I want to have food in my home. We use these statements from the patient to anchor their overall care plan to ensure the care is patientand family-centered. Maggie Sparks, a Care Guide for HealthEast s Maplewood Clinic, describes her experience in this capacity: We focus on the patients pain points. It s up to the patient to determine what s important. We always start with a goal-setting visit and try to understand what has worked or not worked in the past. At our clinic, we focus on lifestyle changes. Sometimes, the patient s goal might not be a scale change, but instead just increasing a patient s self-awareness. The Care Guides come from a variety of backgrounds and must complete a week certification to become a Certified Health Worker within 18 months of their initial hire. The training includes an increased cultural competency, an improved knowledge of barriers to health care, and facilitation skills for goal setting and health promotion for community members and patients. Sparks, for example, was a nutrition and weight loss professional before being hired as a Care Guide at HealthEast. Other varieties of backgrounds for Care Guides include interpreters, financial resource counselors and health coaches. Sharing Individual Stories of Success Sparks notes that one of the most satisfying parts of her job is seeing patients progress to overcome barriers and meet their goals. She explains one patient s amazing path to regain her health as an example of the work being done at her HCH. This older woman was extremely overweight. Her condition had deteriorated to the point that she had developed chronic back pain that made it nearly impossible for her to walk. Her legs would shake violently when she attempted to move. She was severely depressed by her condition and told Sparks that the idea of exercising scared her. Key Components of HealthEast s Health Care Homes ACCESS consistent communication between team and patient and 24/7 access for each patient to the HCH CARE COORDINATION coordination focused on the patient and family-centered care provided by the Care Guide CARE PLAN involvement of the patient and patient s family in care planning and goal setting REGISTRY using an electronic, searchable registry CONTINUOUS IMPROVEMENT evaluation of the quality of each patient s experience and health outcomes and the cost-effectiveness of services Through coaching and use of motivational interviewing from Sparks, the woman agreed to join a gym where they offered exercise classes in a pool. The patient also decided to limit her intake of sugar. Slowly, she started to replace her fatty diet with fruits and vegetables. Less than a year later, the patient has dropped 40 pounds and her symptoms of depression have reduced dramatically. Page 2

3 Seeing the Impact on a Wider Scale The administrative challenges of measuring success and tracking progress for these patients can be substantial. Julie Leibel, a member of the Population Health Analytics team, highlights, It is critical to keep track of who the patients are and where they are at with their health. We ve started analyzing at a basic level, looking at utilization trends both through emergency room use and hospital admissions as well as key measures of our diabetic population utilizing Population Analytics. We re planning on leveraging One in the future to examine more sophisticated clinical outcomes to determine, are we really making a difference for our patients and are we impacting overall organization metrics and goals? HCH Cohort 1 (3_14): Rate of Pts w ED/ER [In Time Period] by Time Where One Adds Value Information 1. IDENTIFYING high-risk patients through predictive modeling 2. AGGREGATING, cleansing and normalizing patient data 3. TRACKING patient clinical outcomes 4. ANALYZING organization financial outcomes 20.0% Rate of Pts w ED Visit 15.0% 10.0% 5.0% Q Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q Time # of patients: 178 Currently, Leibel and the Population Health Analytics team have identified the HCH patients within One and categorized them into cohorts depending on enrollment start date. To date, patients working with an HCH staff member have demonstrated an average of 30 percent reduction in emergency room visits. The patients continue to utilize their clinic, demonstrating downward trends in ER utilization after working with HCH staff over a longer period of time. While HealthEast deployed a grassroots strategy, which allowed providers to determine how best to identify patients that would benefit from additional care coordination, the overall focus centered around high utilizers and patients with depression. As demonstrated in the graph below, the patients selected for additional care coordination had increasing utilization trends up until partnership with HCH staff. Cohort Number Intervention Start Date Rate of Patients with Emergency Room Visits at Intervention Start Rate of Patients with Emergency Room Visits Q Cohort 1 Jun % 11.8% Cohort 2 Jan % 9.7% Cohort 3 Jun % 11.2% Cohort 4 Jan % 14.6% Page 3

4 HCH Enrollees Emergency Department Utilization Rate of Patients with Emergency Room Visit Q-6 Q-5 Q-4 Q-3 Q-2 Q-1 Partnership Q-1 Q-2 Q-3 Q-4 Q-5 Q-6 Q-7 Q-8 Time Since Partnership Cohort 1 Cohort 2 Cohort 3 Cohort 4 Trusting the Data Similar to other delivery systems, HealthEast previously had difficulty monitoring certain cohorts of patients across the continuum of care due to disparate data systems. After adopting One, HealthEast began utilizing the application to create a source of truth for tracking outcomes. Julie highlights, We feel comfortable with the integrity of the data in One and need to move away from manually tracking information. Drilling into the Data In addition to tracking clinical outcomes in One, HealthEast employs Predictive Risk Modeling to identify patients with the highest likelihood of inpatient admission in the next six months for Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and Diabetes. The top 20 percent of patients are brought to the primary care provider by the Care Guide for discussion around the benefits of receiving additional care coordination support. On a monthly basis, each clinic holds a Care Conference to review the status of those patients currently working with a Care Guide as well as to review high-risk patients for future potential referrals enrollment. The final decision is left to the primary care provider to determine whom they would like the HCH team to reach out to for ongoing partnership. HCH Enrollee Clinical Successes Reduced rate of emergency room visits on average 30 percent for all cohorts Increased diabetes education by up to 2.5 times that of the overall diabetic population Reduced rate of hospital admits on average 39 percent since intervention start Reduced mean A1C for all cohorts (4 percent average reduction) Page 4

5 CHF: Patients by Predictive Risk Category Learn more about how can help your organization manage risk. 80.0% Contact us at or Percent of Patients 60.0% 40.0% 20.0% 0 79 (Least) (Less) (More) 95+ (Most) Likelihood of CHF-Related Hosp. within 6 Months Categorized [End of Data] # of patients: 787 HealthEast plans on expanding its use of One to determine what population of individuals needs the most support in care coordination and can benefit from extra navigation. The organization is committed to improving health across all the communities it serves leveraging the Care Guides as a critical component of the care coordination. s analytics and standardized data in combination with HealthEast s well-structured processes for patient-centered care are the essential combination for transformation. 1 Minnesota s Vision: Health Care Homes. Minnesota Department of Health, Payment (webpage), updated March 19, 2014, accessed February 9, About is a leading information and technology-enabled health services business dedicated to helping make the health system work better for everyone. With more than 80,000 people worldwide, delivers intelligent, integrated solutions that help to modernize the health system and improve overall population health. is part of the UnitedHealth Group (NYSE:UNH) Technology Drive, Eden Prairie, MN and its respective marks are trademarks of, Inc. All other brand or product names are trademarks or registered marks of their respective owners. Because we are continuously improving our products and services, reserves the right to change specifications without prior notice. is an equal opportunity employer All rights reserved. OPTPRJ8964