Care delivery models that support effective population health management are uncharted territory. Health care organizations may embrace PHM at the conceptual level, but few know how to get started at a tactical level. It's understandable, given that coordinated, proactive care requires an approach radically different from long-standing, traditional health care models, which provide more reactive care.

The theory behind PHM makes it an enticing idea from a thought leadership perspective. After all, proactively managing health trends should result in healthier patients and lower costs. The challenge for many hospitals and health systems is accomplishing PHM within the limited guidelines and resources available. Implementing a PHM program is difficult because it requires customizing guidelines that take into account the many nuances that surround a particular patient or population of patients.

This is a challenge Christiana Care Health System already is tackling head-on. As the largest provider in Delaware, Christiana is facing the same pressures as most large health systems in successfully navigating new risk-bearing care delivery models. To address the industry's goal "to achieve better health care, better health and reduced cost," Christiana has taken a thoughtful and strategic approach to PHM: It has implemented a pilot initiative, Bridging the Divides, for the care and management of ischemic heart disease. It is anticipated that this PHM model can be replicated not only within multiple departments at Christiana, but also at other health systems across the country.

Christiana received a $10 million grant from the Centers for Medicare & Medicaid Services' Center for Medicare and Medicaid Innovation, to combine new care management workflows with an infrastructure of smart technology, thereby coordinating and personalizing the care of patients with ischemic heart disease. Still in the evaluation and learning phase of the three-year initiative, Christiana is beginning to recognize the advantages of PHM as a foundation of care delivery.

Key Components of Bridging the Divides

PHM initiatives include many components, but Christiana has identified three foundational components needed to successfully introduce a coordinated care model in any health system: a strong technological infrastructure, a well-trained care management team and stakeholder buy-in.

Christiana has found that real-time monitoring of segmented patient populations requires an infrastructure capable of collecting and aggregating data from disparate systems — both inside and outside Christiana. Electronic health records, in their current form, simply are not designed to generate the advanced surveillance, proactive analysis and deep content needs of this kind of PHM initiative.

The first step in Bridging the Divides, therefore, was the deployment of a solid data analysis system to support data aggregation. The PHM infrastructure developed by Christiana uses an intelligent analytic software system to identify important data trends as actionable patient data within the workflows of care managers.

An out-of-the-box solution did not exist for this advanced strategy at the beginning of the project. Consequently, Christiana identified vendors with the expertise to develop systems to support the program's various workflows. The system architecture that has been developed among commercial vendors and Christiana uses data analytics to address patient needs better than the typical one-size-fits-all care plan.

For example, the system is able to analyze disparate patient data from multiple systems to automatically develop an illness acuity score. This score is evaluated by the system in the form of risk-prioritized patient lists that are presented to the care managers for review and intervention. Some patients will receive more attention than with traditional manual care management, while other patients receive less, with the expectation that the specific patient's findings will trigger the appropriate intervention.

Technology alone cannot produce an effective PHM strategy; a care management program is essential to monitor and respond to patient needs. The second foundational component of Bridging the Divides is a multidisciplinary care management team tasked with proactive patient outreach and follow-up based on demonstrated health risk and situation.

A stark contrast to prior "reactive" care models, Christiana's care management strategy entails effectively allocating resources to support a wide variety of tactical options including phone consults, patient home visits, device monitoring and even deploying care management professionals who are embedded within community physician groups.

Due to the level of change management needed to implement Bridging the Divides, buy-in from stakeholders — the third foundational element of the program — also was critical. This PHM strategy requires a completely new perspective of care delivery, so top-down vision and solid communication were essential. Notably, the program was able to get 100 percent support from cardiac physicians by engaging them in the concept of better care for patients — not an easy achievement considering that the initiative demands flexibility with scheduling and an unprecedented level of data integration with the American College of Cardiology's Pinnacle data registry.

Lessons Learned

Pioneering a new concept is difficult. Christiana Care Health System is committed to the PHM initiatives that are essential for reaching the goals to improve population health, enhance the patient experience and reduce costs. Our experience with Bridging the Divides has taught us that:

  • whenever possible, it's good to have the technology infrastructure in place before starting the program;
  • it's essential to properly design care management roles, responsibilities and workflows;
  • the staff should be well-trained and understand the goals and the mission.

In addition, health care organizations must be sure to foster ongoing communication among IT staff, care managers, data managers and clinicians. It is no secret that each of these groups speaks its own language, so leaders must ensure there is no miscommunication.

Ongoing dialogue also helps to set expectations, preventing any unmet or unrealistic goals. Simply put, the way to ensure the long-term viability and accountability of PHM initiatives is to establish an environment in which accountability and support for the initiatives come from the top.

Forward Looking

Bridging the Divide has been in place at Christiana since July 2012 and will run for three years as a pilot program. The first two years are devoted to process implementation and data collection, with outcomes measurement expected to occur in the final year.

Regardless of outcomes, however, participants acknowledge that the program has been beneficial on several fronts. First, it has taught the health system how to deliver care in a multidisciplinary, high-efficiency manner. In addition, while a care delivery model change as significant as Bridging the Divides is never easy, Christiana already has received high satisfaction marks from patients and clinicians.

Throughout the three-year pilot program, Christiana will re-evaluate Bridging the Divides, tweak its processes and use the program to support other initiatives in the PHM realm within the health system. The hope is that by starting this journey now, Christiana can help to chart new PHM territory so other health care organizations can follow.

Please note: The project described was supported by Funding Opportunity Number CMS-1C1-12-0001 from the Centers for Medicare & Medicaid Services' Center for Medicare and Medicaid Innovation. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health & Human Services or any of its agencies.

Terri Steinberg, M.D., M.B.A., is the chief medical information officer and Sharon Anderson, R.N., B.S.N., M.S., F.A.C.H.E., is the senior vice president of quality, patient safety and population health management at Christiana Care Health System in Wilmington, Del.