Population Health Strategies to Keep Frequent Flyers Out of the Hospital

The need to prevent the overuse of expensive hospital-based services is particularly pressing in Maryland, where significant payment reform is well underway. The CFO of Anne Arundel Medical Center in Annapolis discusses its focus "on the top 500 patients that we see the most."

Success in a value-based reimbursement environment requires senior hospital leaders to find strategies to keep people out of the hospital and out of the emergency department, where costs can mount quickly.

Payment Reform Incents Cost Containment
The need to prevent the overuse of expensive hospital-based services is particularly pressing in Maryland where significant payment reform is well underway. In January 2014, the state's global budgeting revenue system went into effect. Under this payment system, hospitals receive a set amount of revenue regardless of how many patients they treat or the services they provide.

Simple Changes for Emergency Department Success

"What that regulation is trying to do is to have hospitals manage their costs, because if you have fixed revenue, you are going to be worried about what you are spending," says Bob Reilly, chief financial officer at Anne Arundel Medical Center in Annapolis.

"It's the biggest financial challenge for us right now because whether we have one patient or 300,000 patients come through the door, we get the same amount of revenue."

Focusing on Heavy Utilizers
To meet this challenge, Reilly says, Anne Arundel is rolling out targeted population health management efforts designed to keep its frequent flyers out of the emergency department and out of the hospital and in the outpatient care setting as much as possible.

"We are working on finding the best methods for reducing readmissions and potentially avoidable utilization… If we discharge a patient who has the potential to come back in for a readmission, for example, we are looking at what kind of structure we can put into place to make sure they are going to stay healthy or stay on the path of recovery," he says.

"Logically, you can't reduce readmissions to 0%, but at any point in time there are probably some health concerns that can be handled without a readmission."

Readmissions: No Quick Fix to Costly Hospital Challenge

One of Anne Arundel's cost reduction strategies is to provide free in-home support to its top utilizers of expensive healthcare resources—those patients with manageable chronic conditions who often present in the emergency department for care that could be delivered in a lower cost setting. 

"What we did was focus on the top 500 patients that we see the most in the ED and in the organization. For those patients who would cooperate, we pay for a care manager to go to their home and meet with them," Reilly says.

"The care managers do education on medication and medication reconciliation. They do an assessment of the patient's social needs and on their access to primary care and the pharmacy."

Care managers are currently working with about 400 patients "to help them create a better lifestyle," Reilly says, and to keep them from needing more intensive and costly services.

Increasing Access to Primary Care
Using a data analytics tool, Anne Arundel was also able to determine that it was receiving an inordinate amount of medical 911 calls from a subsidized low-income senior housing facility in its service area.

Rather than seeking regular primary care to monitor and control health issues like diabetes, chronic obstructive pulmonary disease, and congestive heart failure, many residents were commonly calling 911 to be taken to Anne Arundel's emergency department.

To help these patients receive better, more consistent care and to lower costs, the health system opened a one-doctor primary care clinic in the building in October 2013.

"About two years ago, we began working in collaboration with the housing authority and the state to put a clinic on the first floor. We have a primary care doctor there, and he can see patients in the clinic or he can do house calls," Reilly says.  

The clinic is partially funded through a Health Enterprise Zone grant from the Maryland Department of Health and Mental Hygiene. The HEZ Initiative is a four-year pilot program designed in part to improve healthcare access and health outcomes in underserved communities and to reduce healthcare costs and hospital admissions and readmissions.

The grant provides about $900,000 over a three-year period to fund the clinic. And while that isn't enough to cover Anne Arundel's costs, Reilly says the clinic is still a success when all factors are considered.

"We spent about double [the grant] to build out the clinic, buy furniture, and staff the site. We probably lose about $300,000 a year on it because there is very little reimbursement for those kinds of visits, but it's a good investment in the health of those seniors."

The clinic has also gone a long way toward curtailing medical 911 calls from the building's residents, Reilly adds.

"It's reducing our readmissions and the visits we would have in the ED… It hasn't happened overnight, but over time, we have seen about a 50% reduction in the number of calls from that site to our ED. We are proactively dealing with health issues in an outpatient setting, and that has reduced ED utilization by these patients. It also frees up the ED for more emergent needs."

More Population Health Efforts to Come
Buoyed by the success it has had so far, Anne Arundel is looking for more ways to expand its efforts to work with other patient populations.

"We have just been awarded a $400,000 grant to do some planning for additional population health measures to try to keep people healthy and receiving care in the right place," Reilly says.

Those measures will be implemented beginning in January 2016 and are intended to "help stem the tide" of overutilization for patients dealing with diabetes, obesity, and mental health issues, he adds.

"We want to help people deal with these issues so they don't wind up in the ED or the hospital but, instead, are managed through regular primary care office visits."