Simplifying care coordination for high-risk patients

The previous blog post in this series introduced, HealthEast, a Minneapolis health system using data and analytics to drive success in their medical home care management. This post will discuss how the system applied data and analytics to get great results.

For their care coordination and reporting needs, HealthEast decided to install Optum One, a health intelligence platform that combines comprehensive data and sophisticated analytics with a care management workflow interface. Optum One’s core Population Analytics module aggregates and normalizes EMR, practice management, and claims data for analysis. HealthEast utilizes the Population Analytics database, intuitive analytics and libraries of standard and custom reports via secure web to help them identify high-risk patients for HCH programs through predictive analytics and track clinical and financial outcomes over time.

Identifying, tracking and reporting on their chronically ill populations is the bread-and-butter of HealthEast’s medical homes. “It is critical to keep track of who the patients are and where they are at with their health,” said Julie Leibel, a member of HealthEast’s Population Health Analytics team. “We’ve started analyzing at a basic level looking at utilization trends—both through emergency room use and hospital admissions—as well as key measures of our diabetic population utilizing Optum Population Analytics.”

Currently, Leibel and the Population Health Analytics team have identified the HCH patients within Optum One and categorized them into cohorts depending on enrollment start date. To date, patients working with a HCH staff member have demonstrated an average of 30 percent reduction in emergency room visits. The patients continue to utilize their HealthEast medical home, demonstrating downward trends in ER utilization, even after working with HCH staff over a longer period of time.

In addition to decreasing unnecessary ER use, HealthEast’s medical home model has demonstrated improved clinical outcomes, increased patient engagement and overall satisfaction. Part of that success can be attributed to the organization’s care coordination program.

In the final blog post in the series, will discuss how HealthEast’s care management program is making a difference in the health of their patients. To download the full HealthEast case study, click here.

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