Case Studies

MANAGING AT-RISK POPULATIONS

Centura Health: Creating Solutions, Processes, and Tools to Manage Population Health and Shift the Mindset

Overview

 

Centura Health, a large accountable care organization, standardized workflows and streamlined communication channels to achieve significant clinical improvements in their highest-risk patients.

The Challenge

 

Centura Health wanted to improve quality metrics and the overall total cost of care of their chronic disease populations.

The Approach

 

Created processes to utilize several interventions:

  • Near real-time patient identification (including admissions)
  • Risk stratification
  • Care gap identification and remediation for high-risk patients
  • Transitions of care and care management across the continuum

Developed a clinical pathway to enhance communication around:

  • Patient details
  • Evidence-based guidelines
  • Care and action plans
  • Standing order set to guide care decisions

Outcomes

 

Positive outcomes were seen in:

  • Heart failure—18% reduction in readmissions; 8% reduction in overall annual cost of care
  • COPD—17% reduction in readmissions; 2% reduction in overall annual cost of care
  • Diabetes—11% reduction in readmissions
 

COPD=chronic obstructive pulmonary disease.

 

Milligan S. Reducing hospital admissions through the use of IT. Talk presented at: HiMSS16 Conference & Exhibition; February 29 - March 4, 2016. Las Vegas, NV. https://www.himssconference.org/sites/himssconference/files/pdf/QU3.pdf. Accessed April 21, 2020.