Becker's Hospital Review

33 Clinical Integration & ACOs And it focused resources on the 3 percent of its populations that were using 30 percent of the services. Encouraged by success, Integer put together targeted programs for diabetes, asthma and low-acuity visits to the ED. Again, the approach was low-key — a physician versed in multi-user, multi-programming systems put together a basic dashboard and several nurses became chronic care coordinators. The care coordinators, armed with dashboards, disease registries and electronic care plans, reached out to the patients who came in to the ED the night be- fore, missed their annual check-up or forgot to pick up their prescription af- ter being discharged. Care coordinators drew on their decades of experience to make a personal connection with the patients, educate them and help them do the right thing. They also knew the health system well enough to reach for pharmacists, social workers, case managers and physicians as needed. Tackling the thorny issues After a year of operating under the per-member per-month basis with three payers and showing solid financial and clinical performance, the Integer team felt they were ready to tackle the next challenge — implementing population health across its continuum. It knew that to be successful it had to transform its organization. Out went the hierarchically integrated organizational chart. In came the flat management structure that featured clinical leaders, elevated ambulatory positions and the new chief patient engagement officer. Integer also knew that the economics had to change at a macro and micro level. To support the infrastructure, necessary fee for service contracts would be phased out and Integer made a commitment to value-based contracts. P&L responsibilities were transferred from facilities to populations. New ca- pability investments were made, focused on big data, care management and virtual health. At the micro level, physicians and administrators were now rewarded for keeping people healthy and managing outcomes instead of per- forming transactional care. Still, making the numbers work presented a challenge. The global budget was designed to help the employers lock in a rate while preserving the current reimbursement level for Integer. This meant having to find savings every year to offset the growing costs of salaries, technology and facilities. The savings came from three areas. First, the system reduced utilization of unwarranted medical care, such as low-acuity ED visits, unnecessary MRIs, off-label drug use and preventable hospitalizations. Second, the system set an annual operational efficiency target, supported by initiatives such as staff- ing, to demand and consolidate procurement. Finally, the system was able to reduce some of the administrative complexity related to pre-authorizations and claims processing by hard-coding many of the rules into the EMR. As these changes were rolled out, Martha was faced with increased capacity — and the ongoing need to offset fixed costs. Working with her marketing team, she went on the offensive — touting the increased access to physicians, procedures and ED the system now provided — and was rewarded with an uptick in volume. Martha also partnered with a telemedicine company to give her physicians broader geographic reach and fill their schedules. Finally the care model itself had to change. No more inpatient, outpatient and ambulatory. Now the focus would be on congestive heart failure, diabe- tes, cancer and chronic obstructive pulmonary disease integrated services. Integer set up one of the Midwest's first at-risk population health centers that combined clinical, behavioral and social services. And it began to see the home as a point of service on the continuum of care. Three keys to success Integer's journey toward population health was by no means easy or error- free. For a period of time, the system found itself operating under two oper- ating models aimed at different populations, causing significant discomfort to Martha and driving her to put forward a unified, efficient way of working. Not everyone in management or the physician enterprise was prepared to make the "leap of faith," no matter how well-planned — and some ended up leaving the organization. Finally, once the organization decided to move in the direction of population health, it was inundated with inquiries from payers, employers and vendors — requiring discipline and focus to navigate. All in all, as Martha reflected, she felt there were three things the system man- aged particularly well. When colleagues across the country ask her about her experience at conferences, these are the things she tells them: First, the transformation required clarity of purpose. The leadership team, in a discussion with the board, articulated a set of objectives to achieve over the coming years in terms of outcomes, market share and margin. Every- one agreed that the only way to achieve these objectives was to change the care and reimbursement models. This change had to be controlled tightly, with the system learning and transforming, gradually and profitably. Since that initial conversation, the leadership team would hold a bi-weekly 6 a.m. breakfast meeting, tracking progress and inviting key staff members to report on clinical, operational and financial performance for the target populations. From these naturally data-intensive meetings grew a "command center," helping the leadership team make more informed and timely decisions. The second requirement was leadership and ownership. The success of the transformation was enabled when the physician leadership of the system em- braced and took ownership of the change. They saw it as an opportunity to enhance patient care, increase community impact and attract like-minded practitioners to Integer. Key physician leaders led the charge for greater in- ternal transparency of outcomes and costs, using peer pressure and crafting appropriate incentives to help their colleagues achieve higher performance. Similarly, the nursing leadership took ownership of reducing waste in clinical operations. As with any fundamental change, Martha observed conflict and even departures of individuals who could not see themselves working under the new "regime." However, those who stayed made an explicit commitment to change, and they stuck with it. As Integer rolled out its population management programs and built its ca- pabilities, Martha was reading a lot about the cultural changes that had to take place. Interestingly enough, this aspect of transformation was relatively smooth. Martha and her colleagues found a way to build on the Integer's strengths — its roots in the community, its charitable mission, its historical focus on the health of women and children and the long tenure of its staff. "We have been doing population health all along" — was the message to the team — "before there was even a name for it. Now we can be a regional leader in population health if we hold ourselves and each other accountable and push ourselves daily to make small but meaningful improvements." Through surveys, focus groups and employee forums, Martha and other leaders in the organization helped define a set of behaviors they needed everyone to ex- hibit. In the coming year, they will change their compensation philosophy to make sure they retain, attract and engage employees who value and exhibit these behaviors. The ringing of her phone shook Martha out of her reverie. Refilling her cof- fee cup, she headed back to her office. She was ready for whatever the day would bring. n SUBSCRIBE TODAY! Becker's Hospital Review CEO Report E-Weekly Guidance, analysis and best practice information on hospital leadership, operations and management issues for top hospital and health system executives Each E-Weekly, sent every Tuesday, contains the most popular feature articles covering business and legal issues, CEO profiles and benchmarking and statistical data to immediately inform your decision-making To subscribe to the FREE E-Weekly, visit www.BeckersHospitalReview.com and click on the "E-Weekly" tab or call (800) 417-2035

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