Case Studies
MANAGING AT-RISK POPULATIONS
Centura Health: Creating Solutions, Processes, and Tools to Manage Population Health and Shift the Mindset
Centura Health, a large accountable care organization, standardized workflows and streamlined communication channels to achieve significant clinical improvements in their highest-risk patients.
Centura Health wanted to improve quality metrics and the overall total cost of care of their chronic disease populations.
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
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.