Roundtables

Population Health Lessons From Hospitals in the U.S.' Healthiest Counties: 3 CEOs Share Successes try being agriculture so it is critical to have services in multiple sites and to have strong public health and home health programs. Q: How does your hospital integrate your employed and affiliated physi- cians in the planning and execution of population health initiatives? Ms. Coffey: rough Kaiser Perma- nente's uniquely integrated model — Hospital, Health Plan, Medical Group — we are able to bring togeth- er representatives from all aspects of the healthcare delivery system when planning and executing initiatives, including our network of more than 17,000 physicians. 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 communi- ty 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 popula- tion health without bringing everyone to the table. We all work together to complement each other's services and ultimately create a healthier commu- nity. It's this collaboration that will continue to lead us toward a system of health, not just health care. We directly employ more than 250 ex- ceptional physicians covering primary care and over 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 to care for patients in an era of healthcare reform. WakeMed Key Community Care (the ACO) brings together more than 220 independent primary care physicians from Key with a leading health system and another 250 primary care and spe- cialty providers from WakeMed Phy- sician Practices. is new endeavor represents another step forward in our efforts to work closely with physicians to improve access and quality and pro- vide higher-quality coordinated care in our area and across the state. Ms. Pollard: Educational presenta- tions are offered to both groups at same time. ere is also a routine meeting of all (employed and affil- iated) office staff as they are key to implementation. Q: In terms of population health, what types of data are most import- ant for your planning and execution? Claims? EHR? Labs? Others? Ms. Coffey: Our electronic medical record system is our most powerful internal tool. It allows us to draw data from our 9 million members to identify trends, research best prac- tices and, ultimately, improve health outcomes. For our community health needs assessment, we work closely with the county and state public health departments, reviewing various sets of data, including mortality and mor- bidity 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 Educa- tion 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 im- portant. 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 unmanaged 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. is information is used to create the Community Health Im- provement Plan that identifies the top healthcare priorities in the county. Once these priorities are defined, we "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 continue to lead us toward a system of health, not just health care." Donald Gintzig, MBA, President and CEO of WakeMed Health & Hospitals

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