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38 POPULATION HEALTH 17 Hospitals and Health Systems With Unique Population Health Initiatives By Laura Dyrda H ere are 17 population health programs from hospitals and health systems that have reported success in achieving their goals and creating healthier communities. Aria Health, based in Philadelphia, empowered family physician Rob Danoff, DO, to lead population health efforts designed to close the gap in care for high-risk patients. e hospital implemented preventative screening guidelines for chronic disease management to track patients and make sure they are meeting specific screening recommendations. For example, diabetic patients may need annual tests or check-ups and the program has been effective in getting more patients to follow through with these appointments. Aria Health uses soware devel- oped to identify patients with specific test needs and alert them when to undergo the tests. e physicians' office staff and case management team contact patients to assist them in making appointments for lab tests or necessary procedures. e program has been effective in re- ducing hospital readmissions as well. Atrius Health in Newton, Mass., has been invested in population health for more than a decade, combining care coordination with analytic tools and financial tracking to reduce the cost of care. eir initiatives focus on lowering inappropriate hospitalizations and re- ducing length of stay in nursing facilities. Atrius Health uses histo- ries from Epic EHRs and pairs them with claims data for alternative payment contracts to address any issues. Atrius Health can identify at-risk groups who may benefit from early interventions and man- age those who are already diagnosed with chronic conditions. en clinical teams and case managers tailor care plans for each patient to receive the right comprehensive care. For example, Atrius can identify patients who are at risk for chronic kidney disease and get them diag- nosed and treated sooner. Bassett Medical Center in Cooperstown, N.Y., the foundation for Bassett Healthcare Network, is focused on providing better care for non-compliant chronic patient populations. Bassett Health- care partnered with IBM Watson to implement the IBM Watson Health solution that drove more than 43,000 additional booked appointments between September 2014 and April 2016. The IBM Watson program offered insight into the best way to gain patient acceptance of automated engagement, including fine-tuning the message's content based on community factors and educating pa- tients and staff on automated outreach. Baystate Health, based in Springfield, Mass., and serving western New England, used grant funding to build and execute a care man- agement program for patients with chronic medical and behavioral health conditions. Since beginning the program, the hospital has re- duced readmissions by 15 percent to 60 percent depending on the care setting. Repeat visits to the emergency department are down by 32 percent among patients who frequently use those services and who have complex medical, behavioral and social needs. Catholic Health Initiatives in Englewood, Colo., has taken steps to fit into the value-based healthcare system by managing the health of key populations and keeping people out of the hospital. CHI covers more than 400,000 people with value-based payment plans and has 10 Medicare Shared Savings Program ACOs with around 252,000 covered lives. It participates in bundled payment for care improve- ment initiatives at four sites and plans to add five sites in the future. e system is also employing more primary care physicians as part of its population health strategy. Since employing its population health strategy, the system has seen a 21 percent reduction in pneumonia mortality, 27 percent reduction in catheter-associated urinary tract infections, 34 percent reduction in surgical site infections following colon surgery and 45 percent reduction in SSI aer hysterectomy. By 2020, the system hopes to derive 65 percent of net patient service revenue from sources other than the hospital inpatient care. Children's Health, a pediatric system in Dallas, is evolving population health strategies to care for more families in its community. e sys- tem has telemedicine programs such as the remote patient monitor- ing program, which allows care teams to remotely monitor liver and kidney transplant patients with video conferencing and virtual visits. e system also has a school-based telehealth program, and mobile applications such as My Asthma Pal, a digital action plan for children to manage symptoms and medications. Children's Health is also work- ing with GoNoodle to provide family-friendly interactive videos to get kids moving and Pieces Tech, which provides predictive analytics to reduce hospital readmissions for chronic illnesses. Children's Health is expanding services to provide care for the entire family through Fam- ily Health, allowing the families to see a physician from their home, video kiosk in a local pharmacy or smartphone. Children's Hospital of Orange County (Calif.) has a population health initiative with physicians working in the community to inno- vate in comprehensive care delivery. Mike Weiss, MD, and Shahab Dadjou lead the hospital's efforts to partner with private practice pedi- atricians to develop ambulatory care guidelines for continuity of care in five disease-specific patient registries. e hospital is also investing in technology infrastructure with an EHR platform to enhance infor- mation sharing and care coordination between CHOC Children's and community providers. e hospital works with physician leaders to develop care models that drive quality, value, outcomes and patient experience. CHOC participates in a health information exchange with several other Orange County entities. Christiana Care Health System in Wilmington, Del., piloted a pop- ulation health management program for ischemic heart disease. CMS funded the program — which began four years ago as a first-of-its- kind for practical applications of population health strategies. e program ran for three years and provided several "lessons learned" that inform the population health 2.0 program, which has evolved into a care coordination system aggregating rich patient-level data sets in real time. e program also weaves regressive and predictive analytics into care management to enable more precise care for high- risk populations. Cone Health in Greensboro, N.C., partnered with the University of North Carolina at Greensboro, the Greensboro Housing Coalition and others to develop a pilot project to impact childhood asthma.