In Arizona, the Ambition of “True Care Coordination” is Being Realized
When Equality Health—an Arizona-based integrated delivery system focused on improving care delivery for underserved populations—was formed in 2016, the goal was to look at addressing healthcare outcomes disparities through the lens of culture. “No one in the healthcare market was doing this,” says Mark Stephan, M.D., the medical director of Equality Health. "You see best practices at local levels around the U.S. among certain provider groups, but [they are] not of any scale.”
Stephan notes that the egregious differences in health outcomes based on race and ethnicity are well-documented. And so that is what Equality Health is setting out to do; narrow those gaps. To this end, senior officials of Equality Health—which is headquartered in Phoenix but has a network of providers that stretches throughout the state—say that the organization is able to care for these underserved populations through culturally-sensitive programs that improve access, quality and patient trust. “Through an integrated technology and services platform, culturally competent provider network and unique cultural care model, Equality Health helps managed care plans and health systems improve care for the Hispanic population while simultaneously making the transition to risk-based accountability,” its officials noted.
The IT platform that the organization’s executives mention is HealthBI, a Scottsdale-based company (and which is a subsidiary of parent company Equality Health) that was created by a team of industry stakeholders and physicians to fill the need for tools that enable healthcare payers and providers to reduce admissions and readmissions, automate care transition, and improve value-based care performance and HEDIS (Healthcare Effectiveness Data and Information Set) outcomes. HealthBI’s care coordination and care management platform for population health management, including CareEmpower, is used to accomplish these goals.
Stephan says that HealthBI, as a platform, serves two key purposes for payers today: to close quality gaps and to assist with care coordination, particularly around transitions of care. It’s a way to pass through ADT (admission, discharge, transfer) feeds on that front to the practice directly so that care can be better coordinated from the hospital system, he explains. “Most primary care isn’t going to the hospital anymore. So it’s a way to connect the dots for the average primary care practice, just to know where their patients have been and why they have been to the hospital.”
Stephan points out that because Equality Health is a care delivery system that includes a physician network and an MSO (management service organization), it is leveraging the CareEmpower product for a more comprehensive view from a population health management perspective. “There is a need for the practicing physician to know what has been done, has not been done, and who is either overdue or eligible for certain test procedures, wellness exams, etc. So we have taken and expanded that concept beyond just HEDIS measures,” he says.
For example, Stephan continues, there are process measures in disease management, and if “I manage a population with diabetes, maybe I have 500 patients with diabetes, and maybe 150 of those patients are uncontrolled. If it is left to work as usual, the patients either come back or don’t come back; they get tests and medications, or don’t, and I don’t know unless they show up again or don’t show up. My EHR [electronic health record] doesn’t do this for me. And that’s the great disappointment of the EHR—no matter the vendor—it’s not a population health management tool. It is for documentation and billing,” he says.
Stephan says that Equality Health, as a delivery system that has a network, uses risk stratification in the HealthBI tool and CareEmpower to be able to divide up the work. There are nurse care managers, ambulatory call center care coordination teams, and there is a provider network. “And we divide up the work based on the risk of hospitalization, re-hospitalization, and the risk of future costs. Resources are limited by definition, so risk stratification becomes a practical way to sub-divide the population and reach out to them, engage them, and manage them in different ways with different services and tools. And you cannot manage an entire population with one strategy; so, risk stratification is key,” he contends.
How it’s Being Used
Stephan, when asked about the benefits of the platform, notes that it enables “true coordination of care.” He adds, “It’s one thing for a nurse or someone else to engage a member somewhere in the continuum, make a note and fax it to someone—but that’s not true coordination of care. The ability to communicate on one platform from a health system, hospital, provider network, care management team, and seeing the same set of information—including HIE [health information exchange] participation, which is part of that—is key to understanding in real time what the members need and where they are.”
Another example of the platform being used is at the Mesa, Arizona-based behavioral health provider Partners in Recovery, an organization that is using HealthBI to close gaps in physical healthcare for its members with various behavioral health issues, including severe mental illness.
Leanette Henegan, M.D., chief integration officer for Partners in Recovery, recalls the case of a member who needed state hospital care, which is challenging due to the outpatient resources needed to be utilized in order to enable that care. But Henegan says she was able to pull the member’s cost analysis out of the platform and show that for the frequency she was going to the ED, as well as the regularity of inpatient stays, it would have been cheaper for the member to be at the state hospital. “I have never been able to present that data when trying to justify a level of care. That was paramount; we got excited because the state hospital was denying her, but we showed them the cost variance,” Henegan boasts.
What's more, Stephan notes that social determinants data can also be integrated in HealthBI in one of two ways: they can be incorporated into a person’s risk stratification by using traditional public health data. But, Equality Health also surveys its members. “When you think of the SF-12 [survey that measures functional health and well-being] as a traditional health survey, that’s in CareEmpower, but we also have our own that [includes] cultural preferences and other social determinants. That’s our own standalone risk score for us, and in the software is the ability to embed our survey and score it so that we can begin to share it, use it, and take action on it when we engage members based on their preferences, risks and so forth,” he says.
Speaking more broadly about population health, Stephan says that a true population health management solution should be agnostic of vendors, payers and hospital systems. “You have to be,” he attests; “otherwise, everyone remains in their defensive position and hoards their own data.” He adds that by taking a look at what is happening right now in healthcare, one would notice that there is an absorption of independent practices into ever-larger medical groups. “And that’s been the solution today—well, if we all just get on the same EHR and I employ all the physicians around my hospital system, for instance, that’s [people’s] definition of an integrated system.”
But Stephen says he would argue that there is a tremendous population health need—particularly in primary care around the U.S., in rural areas, in underserved zip codes, and in smaller towns and cities. “You just can’t employ the entire system. So we see a real opportunity, and we need to be able to aggregate through technology and data sharing so that a population can be managed without having to be all under one roof,” he says.
