Reporting, Registry, Risk Calculations Help to Bend Bon Secours Cost Curve

Tuesday, October 9th, 2012
This post was written by Patricia Donovan

Novel HR models like the embedding of nurse navigators, aggressive use of health IT and adoption of emerging care delivery models like the patient-centered medical home are the three pillars supporting population health management for Bon Secours Health System, and in particular, within Bon Secours Virginia Medical Group (BSVMG), explained chief clinical officer Robert Fortini during a webinar on Improving Population Health Management Through Effective, Efficient Data Analytics.

This reengineered approach comes with tools and technology for both the patient and the provider, he explained.

In just 18 months, more than 60,000 patients have enrolled in MyChart®, Bon Secours’ patient portal. Additionally, providers and support staff — in particular nurse navigators embedded in Bon Secours primary care practices — are aggressively using a subset of tools built into its EPIC® electronic health record to identify high-risk patients and more tightly manage transitions of care for these individuals.

The more than 30 Virginia-based nurse navigators get “marching orders” from the daily hospital discharge registry generated by the EHR, Fortini explained. “This is where they begin and end their day,” he said, reaching out telephonically to these patients within 24 to 48 hours of discharge, when they can have the most impact.

The conversations? Chiefly medication reconciliation, follow-up appointments, red flags to watch for. The calling schedule? Three different times during the first week following discharge. If they can’t reach a patient, they send a letter, either in the mail or via MyChart if the patient is using the portal.

Other useful EHR-based functionalities include the ability to identify the “stage” of heart failure for CHF patients, as well as a risk calculator that generates a patient’s risk index based on a host of factors: length of hospital stay, comorbidities, number of ER visits, etc. Patients with a risk index of 11 or greater are considered high-risk and subject to more intensive interventions. Bon Secours also has taken risk management a step further with its development of a “high-risk registry” to identify what Fortini calls “hot-spotters” in need of intensive care management.

“We’re using it very effectively,” he says. “We want to know who our highest risk patients are, and we want to do the most intense management with them.”

The EHR’s analytic tools also help to identify a cohort of patients for intensive disease management. Bon Secours holds condition-specific events, such as Diabetes Day, when patients are identified and invited to the practice for sessions on medication management, retinal exams, and other support. The practices have held similar events for asthma patients, Fortini said, and are planning one for patients identified via its BMI registry.

The more than 18 months of aggressive telephonic follow-up and use of data analytics to continually identify and manage the health needs of its patient population are paying off for Bon Secours, particularly in the critical area of hospital readmissions. “We are consistently averaging a 30-day readmission rate of around 2 percent,” Fortini explained, cautioning that the assignment of patients to a primary care physician is likely contributing to this metric.

“We’re reaching almost 60 percent of our patients this way, and more importantly, setting goals with the vast majority of those that we reach.”

In an industry increasingly focused on value-based healthcare, these practices also ideally position Bon Secours to meet the utilization and quality measures increasingly set forth by the payors with which they are contracting.

Listen to an extended interview with Robert Fortini here.

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