Case Studies

Case Studies

Case Studies

Case Studies

Improving Population Health
Reducing Cost of Care
Enhancing the Patient Experience
Improving Provider Satisfaction
Integrating Data
INTEGRATING DATA

Presbyterian Health: Utilizing Integrated Data Infrastructure as Foundation for Robust Population Health Framework

Overview

 

Presbyterian Health utilized an existing population health model, along with systemwide data and infrastructure, to conduct proactive COVID-19 risk assessment and outreach, reduce disparities, and use remote monitoring for preventive care.

The Challenge

 

Presbyterian Health needed to identify and engage populations at risk for COVID-19 in order to reduce health disparities and adverse outcomes among diverse populations, help adapt virtual solutions for preventive care and disease management, and keep patients safe and out of the hospital.

The Approach

 
  • Analyzed real-time clinical data, claims, SDOH, and behavioral health data to create a complete health picture for each patient and the population
  • Identified care gaps and patients with rising risks due to SDOH
  • Offered proactive solutions:
    • –

      Preventative care (eg, telehealth)

    • –

      Individualized outreach (eg, medication delivery)

    • –

      Chronic disease management (eg, healthy meal deliveries)

  • Implemented remote monitoring (eg, oxygen levels, temperature) to enable select members diagnosed with
    COVID-19 to safely recover at home

Outcomes

 
  • Identified >20,000 members at risk for adverse COVID-19 outcomes using systemwide data
  • Shifted 80% of primary care visits to telehealth to ensure continuity of preventative care
  • Avoided hospitalizations and ED visits with remote monitoring
  • Reduced COVID-19 exposure with home delivery of chronic condition medications
  • Stressed importance of lifestyle management with the delivery of 2 weeks of healthy meals

For more information, visit Becker's Hospital Review

 

ED=emergency department; SDOH=social determinants of health.

 

Robran-Marquez D. Addressing patient and member needs during the pandemic: a robust population health framework is key. Becker’s Hospital Review Website. https://www.beckershospitalreview.com/care-coordination/addressing-patient-and-member-needs-during-the-pandemic-a-robust-population-health-framework-is-key.html. Published August 5, 2020. Accessed August 21, 2020.