The health care industry is at a tipping point. Health care organizations have largely adopted electronic health record (EHR) technology to improve the quality and safety of care delivery. As organizations endeavor to improve the health of patient populations, the EHR by itself is no longer enough. We need to start thinking beyond what is happening in our systems to better understand and care for our populations.
What goes into a comprehensive population health management strategy?
An essential step in developing a population health management strategy is understanding the population. The medical services and insurers currently available to a population, combined with the demographics and the myriad cultures, all shape the particular needs and desires of a community.
A comprehensive strategy will consider all these factors and how they play across the health continuum, taking stock of the primary care versus specialty care services and whether those services are appropriately spread across the population.
Ultimately, a comprehensive population health management strategy looks to advance the quality of care, provide better access to care and increase preventive care, thereby improving health outcomes of a population.
Identifying gaps in the health of a population
Knowing a population means being able to identify gaps in the health and care of that population. Children's Hospital of Orange County (CHOC Children's) in Orange, California, has had full at-risk responsibility for a managed Medicaid population, now numbering 156,000 children, for the past 20 years. When we studied a Hispanic, inner city subset of that population, we found that significant bronchial asthma was present in over 20 percent of children — a figure more than double the national average.
The rate of children with asthma has been steadily increasing over the past three decades, largely due to under-diagnosis and under-treatment. When we consider the effect of untreated asthma in terms of psychological, economic and physical costs to an individual, the evidence is staggering.
Asthma is one of the leading causes of hospitalization and emergency department visits for children. It's also the leading cause of school absenteeism. In Orange County alone, we've found that 40 percent of children miss five or more school days a year due to asthma; approximately 30 percent of children visit the emergency room and 5 percent are hospitalized each year because of this condition.
Knowing how to manage asthma is one thing, but we've found that one of the biggest problems our population has is adherence to or compliance with a treatment plan. Compliance starts with trust and bonding with the doctor, and the parent needs to be educated on all elements of the treatment plan — especially when it involves medication and allergy injections. When that education is present and families can bond with the physician, parents go into a preventative rather than reactive mode.
At CHOC Children's, we realized we had a significant gap in the care of our population when it came to diagnosing and treating asthma. We needed to adjust the way we delivered care to children with asthma so that it could be more accessible to our population, raise awareness and increase preventive care.
Data drives the strategy
We have both EHR and external data from approximately 29,000 asthma patients, which helps us further the knowledge about how to approach and treat asthma. The more data we obtain, the healthier our population health management strategy becomes.
Here's how it works: At CHOC Children's, we've implemented a cloud-based population health management platform, capable of aggregating and normalizing disparate data, as the foundation of our population health management strategy. We have numerous sources feeding data into the platform, such as outside labs, claims data from our IPA and data from our EHR. This information powers our registries for asthma and other chronic conditions.
The registries let primary care providers track quality measures that have and have not been completed according to clinical guidelines and best practices for a particular condition at a population and individual level. Since the implementation of the asthma registry, we have seen a 26 percent increase in asthma action plans and a 47 percent increase in documented asthma control tests.
On a broader scale, the registries provide transparency to our quality performance at various levels. With registries, we can see what areas are doing well and what areas present an opportunity for improvement, so that we may adjust our strategy accordingly.
Thinking beyond the four walls
Population health management requires outside-of-the-box thinking that looks at not just how we're using our data, but also how we're providing our services. At CHOC Children's, we needed to find a way to make asthma treatment more available for our population. Rather than building new infrastructure and giving individuals more location options, we considered an alternative: What if we went into the community and met individuals where they live and attend school?
The concept of taking the medical facility to where the patient lives seem like a new idea, but in a way, it's a return to the old days when doctors regularly made house calls. There's a great deal of comfort for the patient when they're receiving care in an environment that they're accustomed to, as opposed to going to a formal doctor's office.
We began thinking of creative ways to see children with asthma at inner city schools, and in 2002, the CHOC Children's Breathmobile program was launched. The goal of the program is to provide access to preventive asthma care and improve quality of life for underserved children. Our two 36-foot RV-style clinics travel to 22 schools and community sites across Orange County, providing asthma care, diagnosis and education and incorporates the use of the registries to capture data and provide decision support.
Each location is visited every four to six weeks, meaning children have comprehensive follow-up care with a familiar team until their asthma is under control. Because the Breathmobile staff is the same, families see the same provider and even the same driver.
Providing health care across the continuum
A population health management strategy considers individuals across the continuum of care, which means that to truly improve the lives of patients with asthma, we need to ensure that their treatment is ongoing and health information is expanded beyond one venue. Continuity of care is too often a missing component in medicine, and patients with persistent asthma need to be seen regularly — not just once, or on a day when their asthma is particularly bad. Additionally, their care team should be well-versed in their most current health care information.
Because our Breathmobiles visit the same site every four to six weeks — and sometimes more frequently than that — we've seen outstanding results. Since the program began, the Breathmobile has provided asthma care to more than 6,500 children. For patients followed by our Breathmobiles, we've reduced school absenteeism in Orange County by nearly 80 percent, and we've decreased the emergency department hospitalization by nearly 60 percent. Additionally, approximately 75 percent of our children have well-controlled asthma — more than double the national average of children with well-controlled asthma, which is approximately 35 percent.
With proper asthma care, children are proven to have a higher quality of life. Beyond improving patient outcomes, we've had significantly high numbers in terms of patient satisfaction. More than anything, the registries and Breathmobile program have made us rethink health care as a community service and led us to consider what other specialties might be suited for a similar program. Health care organizations need to think bigger about how we're providing care — and this is one step forward in that direction.
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