In addition to highlighting its impressive results in value-based care contracts and several new care coordination initiatives, a 2022 annual Clinically Integrated Network Value Report from the Orlando Health Network in Florida provides details about how technology solutions are supporting population health initiatives and quality reporting.
As Erik Walker, M.D., board chairman of Orlando Health Network, describes in the introduction to the report, Orlando Health Network (OHN) and Bayfront Health Network (BHN) are Orlando Health’s clinically integrated networks that serve the central and western Florida marketplaces, respectively. They represent the largest networks in the region with more than a quarter million lives under management in various value-based arrangements across 13 counties. The network includes more than 5,700 multispecialty providers who have earned more than $160 million in cost savings since the founding of the network.
Orlando Health’s instance of Epic, known as ELLiE, has its own population management application called Healthy Planet. As the report explains, the Healthy Planet application ingests medical and pharmacy claims data along with other external data feeds to allow the network to analyze information on its value-based care (VBC) lives to better perform care management and quality reporting functions.
The report details how the network’s quality performance team uses Healthy Planet dashboards to track and trend performance across all VBC arrangements. “These reports are capable of incorporating clinical and administrative data sources to create a holistic view of an individual patient and, consequently, present more accurate performance information,” the report says. “This reporting also allows for better identification of patients requiring more care coordination due to their complex care needs while simultaneously providing a common platform for communication between care team members.” The quality team can summarize performance across all measures on aggregate or individually to understand both network and provider-specific areas of opportunity.
The care coordination team uses the Healthy Planet platform to identify, stratify and assign cases to the network’s clinical resources, the report states. Cognitive risk modeling identifies at-risk patients and seeks to enroll those who may benefit most from the network’s clinical programs, such as disease state management or transition-of-care services, according to OHN. Care management dashboards update in near real-time and allow for summary and granular views of the patient, including access to more than 40 quality measures. OHN providers can leverage patient “pursuit lists” to identify members overdue for preventive and maintenance care services, offer scheduling options to see providers capable of managing their condition needs, and, ultimately, close all gaps in care.
ELLiE also features an analytical tool called SlicerDicer, which allows users to filter, sort and analyze data in various ways to glean insights across the network’s patient population. This self-service tool provides actionable information from large sets of data, thereby shortening the time it takes for providers to receive the information necessary to improve healthcare outcomes and contain unnecessary healthcare expenditures.
InNote and InConnect
Using the insights generated through the platform, such as care gap listings, cost and utilization reporting, and risk-coding analytics, providers can make informed decisions for their patients. Although the tool is largely built to be used in real-time during the patient encounter, OHN says it also can be leveraged by office staff to proactively plan for upcoming appointments and outreach to patients. From a performance perspective, the network says, InNote users have experienced greater practice efficiency, better patient outcomes and marked improvements in their value-based program results.
The value-based care team also has launched an interactive patient engagement module called InConnect, also from Innovaccer. The platform offers bulk messaging and patient outreach functionality to further support network physicians in encouraging patient participation in their care (e.g., medication adherence).
Using various channels of communication, such as text, e-mail and phone messages, patients can receive notifications about overdue/upcoming visits, outstanding screenings and prescription refills, among many other targeted messages. The InConnect platform also allows for two-way patient interactions in response to all outreach campaigns, thereby allowing for greater patient interaction and more tailored care plans. In 2021, the organization said, 11,865 aligned members were successfully contacted and took the necessary steps to close their care gaps in the plan year.
Walker also described several highlights of 2022, including the development of a Network Performance Committee that advises the OHN board of directors on quality, operational, financial and risk management improvement opportunities across their value-based arrangements and provider network
OHN has deployed new bundled payment care management initiatives, focused on coordinating patient care journeys across multiple stakeholders in an effort to comprehensively manage various episodes of care with appropriate care transitions and skilled nursing facility utilization.
In addition, it has updated its post-acute care network using enhanced performance metrics to compare partner organizations to program targets and peer benchmarks, allowing the network to better support patients across the continuum of care post-hospitalization.
