How Adventist HealthCare Supports Its Care Navigation Teams

After participating in the Maryland Primary Care Program for several years, leaders of the Adventist HealthCare Physician Alliance, a clinically integrated network with over 2,400 physicians, felt that the time was right to join the CMS Medicare Shared Savings Program in 2024. Mary Kim, M.D., chief medical officer and vice president of population health, physician enterprise, at Adventist HealthCare, recently spoke with Healthcare Innovation about their value-based care journey and the care navigation solutions supporting this work. 

Adventist HealthCare Physician Alliance providers in metro DC/Maryland partner on value-based care and other population health initiatives. The group represents primary care and specialty care practices who also partner with Adventist hospitals across the continuum of care. Also joining the discussion was Jacqueline Cruz, M.S.N., R.N., director of care navigation at Adventist.

Healthcare Innovation: Was there something about 2024 that made your team feel ready to participate in MSSP or were there changes in the program that made it look more appealing than before?

Kim: After participating in the Maryland Primary Care Program for several years, we had developed a lot of workflows around quality and utilization, and were really hitting a good rhythm with that. We also knew that CMS had really committed to try to have all of their Medicare population in a value-based care arrangement by 2030, so we wanted to make sure that we were participating in all of the structures that would support that progression and that maturity. Those are the reasons that we decided that this was the right time for us to engage and make sure we were continuing to build our value-based care foundation and infrastructure. 

HCI: Could you talk about some of your responsibilities as CMO and vice president of population health for the organization?

Kim: In terms of our population health programs, I oversee all of our clinically integrated network, and all of the Medicare and commercial programs that are underneath that. We have a team that's focused on our advanced primary care practices. We have a team that's focused on our medical neighborhood — the infrastructure and partnerships that primary care practices will partner with in patient care. We have a large community health program that focuses on building community partnerships and also educating patients in terms of their self-management. We have a heavy emphasis on diabetes education as well, and that infrastructure is coordinated by our care navigation team, which is a team of nurse care navigators embedded in our primary care practices. They work to capture and support our higher-risk patients and help them through their health journey in partnership with our primary care practices. 

I work with a large team of care navigators who make sure that patients are transitioning effectively from the hospital into the community and are able to engage in all the resources they need for their ongoing care and re-establishing care with their primary care providers to ensure that they're able to sustain their health upon discharge.

HCI: Has that care navigation role been in existence for a while and is technology enhancing their effectiveness? 

Cruz: The care navigators have been embedded in primary care for a while. But before it was a manual process in which the care navigators would pull Excel sheets and start reaching out to patients. Now the process within the Innovaccer platform is that we get automation for the ADTs [admission, discharge and transfer notifications]. The nurses are assigned specifically from the primary care practice and the payer. We have, for instance, one nurse that's only assigned to CareFirst, and then other nurses assigned to our other programs. They sign in on a daily basis, and they see their workflow. They know which patients they need to follow up on that day, and they also work on high-risk patients. We have an algorithm Innovaccer has created  so that patients are screened as high risk based on previous labs, previous claims, and previous utilization. Innovaccer allows us to prompt each care navigator following the specific protocols that are assigned to them. 

HCI: In the clinically integrated network, do you have practices that are on a multitude of different electronic health records, and does that add some complexity?

Kim: It's a challenge for our system, but I think other systems face this challenge as well. We don't live in an ideal world by any means in terms of interoperability, but I do really appreciate and value the functionality that Innovaccer has provided in integrating a lot of that data and also providing a common platform that is efficient, that has really suitable and reliable workflows that enable our care navigators to work effectively with their patients. It helps them prioritize which patients to work with. I do think that it really impacts the ability to ensure that you're giving patients optimal care, especially the patients that particularly need it.

HCI: Have you already been able to see an impact of using this platform on readmission rates?

Kim: We have been able to improve and maintain great performance with inpatient utilization and emergency department utilization. We often look at readmissions, and it's really kind of a downstream issue. We have really tried to work in more longitudinal care, where we're capturing patients even before they’re hitting the thresholds that require hospitalization or ED visits. So we've seen that be very impactful for our ED utilization and our inpatient utilization measures.

HCI: Are there other things the clinically integrated network is still working on, or challenges you still face that you're fine trying to fine-tune?

Kim: We talked about utilization, but we have a lot of efforts that are focused on the quality of care, and especially preventive care and optimal chronic disease management. Innovaccer has been a really good partner in helping us to identify gaps and to work on closing those. The other area that we're currently working on is trying to optimize our cost utilization. As you can imagine, that is very complex in terms of all the factors, particularly in this environment, with a lot of the national trends and different inflationary costs. 

HCI: One thing we hear often is it's been more challenging to engage specialists in value-based care — that it’s more naturally focused on the primary care physicians. Do you feel like the specialists in your clinically integrated network are engaged and that it's meaningful to them?

Kim: Yes, I think that's one of the significant strengths of our clinically integrated network. We have a very large membership. They actually meet on a quarterly basis and share best practices and learnings. There's a deep partnership between our primary care practices and our specialty care practices, and we actually do support the management of those relationships in terms of the referrals and ensuring that the needs of both the patients and practices in regards to communication and access are being met. I think that the MSSP program obviously provides a lot of infrastructure around furthering value-based care in our populations. I think the clinically integrated network is a special vehicle or framework that allows for that enhanced specialty care partnership as well. 

HCI: Have you done work to build clinician engagement in decision-making?

Kim: Yes, we've definitely built that into our governance structure from the board level down. They do have a lot of say in terms of guidance on our approaches to how we integrate the network. Within that, we have a medical neighborhood committee where we really focus on all of our efforts in terms of making sure that we have effective partnerships and collaborations. We also have a clinical committee that works on a lot of the clinical pathways that may be more primary care-specific, particularly with preventive care and some of the other quality areas. But those two committees really drive a lot of the initiatives. Updates and feedback are brought to our quarterly meetings where we have a large group of the leads of all of the primary care and specialty practices joining and providing some level of oversight and feedback to all of the work that's being done at the committee level.