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Population Health Management Strategies: Creative Ways to Use Population Care Managers in ACOs

This is the final post in my three-part series on the successful implementation of Population Care Managers (PCMs) within Accountable Care Organization (ACO) and Patient Centered Medical Home settings. Population Care Managers (PCMs) are registered nurses who are specially trained inbehavior change, coaching techniques, decision supportpopulation health management, and how to interpret and use analytic tools to drive primary care practice and ACO transformation. Each nurse performs three central functions: care coordination, educational coaching services, and the development and execution of patient outreach strategies. Health Dialog’s PCMs use our advanced analytics to create step-by-step plans that support population health management initiatives, one provider and practice at a time.

The primary objective for any ACO or at-risk provider is to deliver value-based care and reduce wasteful spending. A key challenge is the ability to increase the use of preventive care services as this requires sophisticated patient identification and effective engagement. Below are a few examples of innovative population health management campaigns launched by ACOs with the help of population care managers, who leveraged analytical tools and engagement expertise.

1. Mammography Screening

One PCM introduced and developed the first preventive health strategy adopted by her ACO; amammography screening campaign to take place during Breast Cancer Awareness Month. She organized a small group of health system employees who volunteered to support the initiative. They drafted an annual mammogram reminder letter to all eligible health system patients, identified by Health Dialog’s analytics. The letter contained the contact information of the ACOs participating mammography sites for easy access. They coordinated with these sites in advance, in anticipation of an influx of appointment requests, and wrote an email and FAQ guide to prepare each primary care practice in the network to answer patient questions and handle referral requests.  The campaign was so successful this system is implementing similar campaigns to highlight other critical diagnostic screenings throughout the year.

2. Patient Retention Initiative

Another PCM started a new process for reaching disengaged patients. She uses Health Dialog’s analytic target lists to identify any patient with a chronic condition who has not been seen by their primary care physician (PCP) in one year or more. She contacts each patient, educates them on the importance of regular visits with the PCP, addresses any barriers to care, and helps them prepare for their visit.  When a patient’s doctor is no longer within the network she assists that patient in identifying a primary care doctor who is.  This effort contributes to continuity of care and ensures no patient is lost to the system. Since our data is refreshed regularly the PCM is able identify new groups of patients that fit the criteria every 4 weeks.

3. Diabetes Foot Exams

Two PCMs, assigned to the same ACO, studied Health Dialog’s analytic reports and established that only a small percentage of patients actually had diabetes foot exams. They set out to increase the number of exams being performed in the offices. First, they explained their findings and received ACO leadership’s agreement to move forward with a multi-prong approach. They then introduced the proposal to the doctors at the practices and asked for their participation and input.

Below is a list of several of the interventions they implemented;

  • The PCMs educated all patients with diabetes that they coach on the importance of diabetes exams using evidence-based education tools and fulfillment materials.
  • Medical assistants (MAs) attended specialized training sessions; including why foot exams are important and how to conduct monofilament testing.
  • Posters were hung in exam rooms encouraging patients with Diabetes to take off their shoes and socks at every office visit.
  • MAs performed monofilament testing on all patients with diabetes and entered results in the EMR in a consistent and reportable field.
  • Doctors were encouraged to reinforce the need for diabetes foot exams with patients and perform the test if the MA is unable to do so.

Within three months of the campaign launch, there was an increase in the number of exams performed.

Please join the discussion and let us know how your health system has integrated population health management initiatives.

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