Becker's Hospital Review

21 and executing initiatives, including our network of more than 17,000 physi- cians. In the community, our physicians also bring a valuable medical voice to various population health initiatives, such as increasing regular physical activity, providing access to healthy affordable foods and creating a broad network of community connectors and support services. In Marin [County], 25 of our physician leaders serve on 32 local, state and national committees and boards. Mr. Gintzig: You can't achieve population health without bringing everyone to the table. We all work together to complement each other's services and ultimately create a healthier community. It's this collaboration that will con- tinue to lead us toward a system of health, not just healthcare. We directly employ more than 250 physicians covering primary care and more than 20 specialties through our WakeMed Physician Practices division. We support our growing network of engaged physicians and ensure their needs — both employed and otherwise — are represented and met as we look for new ways to work together. WakeMed Key Community Care (the ACO) brings together more than 220 primary care physicians from Key Physicians, a community-based network of independent medical professionals, with a leading health system and the physicians from WakeMed Physician Practices. This new endeavor represents another step forward in our efforts to work closely with physicians to im- prove access and provide higher-quality coordinated care in our area and across the state. Q: In terms of population health, what types of data are most im- portant for your planning and execution? Claims? EHR? Labs? Others? Ms. Coffey: Our electronic medical record system is our most powerful in- ternal tool. It allows us to draw data from our 9 million members to identify trends, research best practices and, ultimately, improve health outcomes. For our community health needs assessment, we work closely with the county and state's public health departments, reviewing various sets of data, includ- ing mortality and morbidity data, as well as substance abuse, drinking and tobacco consumption figures. With a commitment to our young people and thriving schools, Kaiser Permanente works closely with the Marin County Office of Education to review and analyze student behavior data surveys to support and encourage healthy food choices on and off campus, as well as raise awareness and minimize high-risk behaviors, including binge drinking. Mr. Gintzig: All of these are important. Data helps us identify those patients who are using extensive resources within the health system and analyze why. For example, if a patient has repeated emergency department visits due to un- managed diabetes, we can identify the issue and then work with care managers and primary care physicians to help the patient manage his or her health. Our system-wide electronic record implementation will further help us capture this data and alert caregivers before the issue is trended in claims data. Ms. Pollard: An annual community health needs assessment is completed every three years in partnership with our rural health network that includes county health data, behavioral risk factors, community survey and focus groups. This information is used to create the Community Health Improve- ment Plan that identifies the top healthcare priorities in the county. Once these priorities are defined, we can drill down on the utilization of services and identify opportunities to improve healthcare outcomes in the most cost effective manner for the system. Q: What best practices for population health have you found in your hospital? How do you distribute those best practices to the community of providers and patients? Ms. Coffey: Not only is Marin County one of the healthiest counties in the country, it is also one of the oldest. One in four adults in the county is 65 or older — higher than the California state average and the nation. We at Kaiser Permanente believe prevention is for young and older adults alike. We are committed to improving heart health and working to prevent heart attacks among our members, as well as improve the outcomes for patients admitted with serious heart attacks. Over a 10-year period, our Preventing Heart At- tacks and Stroke Everyday efforts have resulted in a 24 percent decrease in heart attacks and a 26 percent reduction in stroke mortality. Today, Kaiser Permanente Northern California members have a 30 percent lower risk of dying from heart disease than the general public. Mr. Gintzig: The more you know about your health, the better equipped you will be to manage your health. Healthcare systems and providers play a cru- cial role in promoting, providing and educating patients about preventive services and screenings and maintaining their health. WakeMed treats more heart patients than any other hospital in North Carolina. Through support programs, like our congestive heart failure program, we are able to work closely with our heart patients and their families to minimize risk for hospi- talization and manage their conditions. We established the CHF program in 1999 — a time when follow-up care was an unexplored area. Between 100 and 150 phone calls are made each day as part of the program's follow-up care. And the patients are listening. The per- centage of CHF patients returning within 30 days was 14 percent in our latest reporting period, and we've been as low as 10 percent. Additionally, having accurate information about a patient's primary care provider is necessary for coordinating care across the healthcare continu- um. This concept of coordinated care is especially important for success- ful population health programs, like the WakeMed Key Community Care ACO. Our goal is to provide the best care for patients during an acute epi- sode and return them to their primary care physician for follow-up and preventive care. Ms. Pollard: Within the last year, the hospitalist group for Noyes became the medical providers for the Livingston County Center for Nursing and Reha- bilitation, a 262-bed facility. Prior to this change, data demonstrated a higher than average readmission rate and possible preventable admissions. Having a single group manage the residents at both sites improves continuity of care, is anticipated to decrease admissions and also decrease length of hospital stay. A Continuum of Care Coalition, which includes representatives from more than 30 healthcare and human service agencies, was started this year. The goal of the group is to improve communication, increase awareness among providers of available services and address barriers to health care. n • Arcadia Healthcare Solutions builds advanced provider networks for leading health systems and health plans. The transformation required to achieve a sustainable healthcare enterprise will be driven by those organizations able to maximize the value of their provider networks • Arcadia's analytics and improvement technology platform delivers immediate insight into the care team activity, workflow efficiency, and practice performance across the entire provider network. This allows Arcadia's coaches and consultants along with client internal staff to achieve and sustain quality, financial, and operational transformation. • Founded in 2002 and headquartered outside Boston, with offices in New York, Seattle, and Nashville, Arcadia Healthcare Solutions is an innovative and nationally recognized leader in the healthcare technology and services industry. Arcadia has worked with over 10,000 providers in 37 states caring for 12 million patients to thrive in today's fee-for-service environment while performing in an emerging population health, shared-risk, and fee- for-value future.

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