Iowa hospitals work to treat complex, low-income patients through population health management

Population health management. It's the term du jour in the health care industry. But what is it? And more important, why is it something health care providers, payers and industry watchers are spending so much time talking about?

The idea behind it is actually quite simple — using data to target high users of the health care system who are likely accepting services in an inefficient way. Once that person is identified, health care providers work to treat that individual's medical needs as well as his or her social needs. This makes the person healthier and less likely to come back into the emergency department for additional expensive services.

'As payment for health care services moves from unmanaged payment for every unit of service delivered to a more managed notion focused on health outcomes for patients, the way one maximizes revenue then is focused more on patient health than it is on specific encounters on clinical care when health goes awry,' explained Keith Mueller, interim dean at the University of Iowa's College of Public Health.

But putting that idea into practice is, of course, more complicated.

For example, a patient with diabetes comes into the emergency department for care. Doctors can prescribe insulin to treat the diabetes.

But is the patient able to afford the medication? Does the patient have a refrigerator at home to store the insulin? And can the patient pay the utilities bill to keep that refrigerator running? Do they have the ability to buy healthful foods to better manage their diabetes? And does the patient have the ability to get to a primary care doctors office for routine checkups?

'When you address that, you're in the realm of human and social services — not clinical care,' Mueller added. 'There's no way for a physician to know all of that. That's when you start building systems to address these issues and build partnerships.'

To do so, Mueller said, health care providers have to go outside the four walls of a clinic and work collaboratively with agencies to address a person's social determinants of health — factors such as education levels, economic stability, employment, social supports and even the neighborhood in which a person lives that can influence someone's overall health.

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Insurers benefit, too, when customers make better health decisions

But tight budgets and busy schedules can keep organizations in silos.

'In the ER, you have to deal with and treat them in the ER so you're ready for the next trauma victim or heart attack victim,' Mueller said. 'I'm focused on what I do well and that's all. There's also chronic underfunding in agencies involved in social human services. They would (work collaboratively) if they could be focused on the bigger picture. But resources are so tight, they're focused on their little piece.'

Finding the money to pay for this kind of health care can be a challenge — the system is just not designed that way in a fee-for-service world — where insurance companies pay providers for each test, surgery or appointment — but it's slowly moving in that direction through value-based care.

But to really get an idea of how population health management works, let's look at what two Iowa hospitals are doing.

Building partnerships at Jennie Edmundson Hospital

'You've got someone who comes by and checks on you, right?' Tami Bardon asks Ila Fernhetzel one morning in late June.

The 78-year-old farmer has cardiac problems and was having breathing issues after cleaning her windows on a hotter-than-normal weekend. So she drove herself to the emergency department of the Council Bluffs hospital.

Bardon peppers her with questions — can you get in and out of your basement safely, do you put your pills in a pill box, can you afford to refill all your medicine — and enters the answers into a computer.

The TAV record — separate and different from an electronic health record — later can be accessed by all the Community Health Partners — a group of nearly one dozen health care providers and social service agencies that work collectively to treat the chronically ill, elderly and low-income.

The group includes Jennie Edmundson Hospital, behavioral health services, the area agency on aging, Iowa Legal Aid, home health care, and a handful of different case managers such as Bardon.

'A lot of experts these days are talking about how the ZIP code where you live is more important than your genetic code...Is there access to transportation to use? Is it easy to buy healthy foods?'

- Becky Wampler

Director of Health Care Sustainability, Wellmark Blue Cross and Blue Shield in Des Moines

The program was born from the hospital's desire to lower its readmission rates, said Lorrie Reddish, director of case management at the hospital. Back in 2012, Jennie Edmundson was facing the prospect of high Medicare penalties — when the federal government keeps a portion of Medicare reimbursement if too many patients return to the hospital within 30 days of discharge.

With 70 to 80 percent of its patient base receiving either Medicaid or Medicare, Reddish said, the hospital realized it needed to do something differently.

'We needed to get outside of our walls,' she said. So Jennie Edmundson went to Connections Area Agency on Aging and developed a pilot program.

The hospital began to see readmission rates drop — by nearly 20 percent — and Community Health Partners expanded to include more social service agencies and a bigger portion of the hospital's patient population.

'It started out a little as a territorial battle,' Reddish said. 'But now it's really a team effort.'

But the program does more than coordinate care between agencies. It's set up a clothes-loan closet for low-income and homeless patients and a voucher system to help people pay for transportation services and prescriptions. They've helped furnish someone's house, fixed someone's car and even went toe to toe with a landlord to get a toilet fixed — the broken toilet was in the apartment above the patient's and was leaking water through the ceiling for months.

And for the most part, the partners are doing this without any additional funding. The group obtained some grant money after the initial pilot proved successful. But that funding has since ended, and now the organizations all are committing dollars to cover the costs while the hospital has absorbed the costs of TAV records system.

That record is crucial — all the groups have access to the record, unlike with an electronic health record, and can input important information such as the patient's most recent phone number and what the inside of the home looks like. All this information helps each individual Community Health Partner and the collective group provide the necessary care and keep patients accountable.

They'd like to expand the program further to include the school district, fire department, police department and paramedics. But, unfortunately, securing additional dollars is key.

Healing people head to toe at Mercy

'Are you still having nightmares?' Alindsey Gengler, a nurse practitioner, asks Bryan Finn.

The 31-year-old Army vet who served two tours in Iraq has been having trouble sleeping. He and his wife have a new baby at home but he also struggles with anxiety and post-traumatic stress disorder.

Finn shows her some photos of the new baby and brushes off the question by making a joke — no one in the house is really sleeping with a one-month old, he says. But Gengler persists. This time she gets a better answer — he is. So she tells Finns she's going to make some adjustments to some of his medications.

She talks with ease to her patients — making jokes and asking for life updates. But in those conversations she asks sharp questions to gauge their health and how their medications are working. During Finn's appointment, she brings up smoking cessation — something he isn't interested in at the moment — and she tells him she'll be there if he ever is.

'Alindsey is my people,' Finn said. 'She's easy to talk to. At the VA they deal with you like you're a number.'

That's exactly what Gengler, along with Dr. Monica Meeker and social worker Deanna Glass, are trying to avoid at MercyCare Health Partners. The Cedar Rapids's clinic works with low-income patients with complex health care needs — patients on dialysis, dealing with stage 3 or 4 renal failure, cancer diagnoses or serious mental health issues. Some are uninsured, some are homeless and many are on Medicaid.

The clinic, started about four years ago by Dr. Brad Archer, deals with patients unable to find or maintain care elsewhere. The providers see patients more frequently and spend more time with patients than at a typical doctor's office — they offer a good deal of education and help patients grow more comfortable with using the health care system.

Since Meeker has taken it over, she's worked to grow it into a four-day-a-week operation — up from two half days a week. Meeker previously was the chief medical officer at Community Health Centers of Southeastern Iowa — a federally qualified health center that provides primary care services to low-income populations — in Burlington.

She also has added therapy and pharmacy services. Meanwhile, Glass works relentlessly to help patients find anything and everything they may need outside the clinic to live healthier lives — clothes, shoes, shelter, medicine. She once even helped someone get a fishing license.

'Really, I'll help them find anything,' she says — seconds before she is on the phone arranging transportation home for a patient being discharged from the University of Iowa Hospitals and Clinics.

'Transportation, counseling, services of at Abbe or ASAC, dental, the eye doctor,' she says, rattling off a few before being interrupted by the phone again. As soon as she hangs up, a nurse pops her head in the door to tell her about a new patient who likely will need some referrals.

'I try to see every patient and meet with them once,' Glass says. 'And then a lot of it is on the phone checking up on them.'

These women help patients feel comfortable and listened to. And most importantly, they earn the trust of their patients.

'I've felt belittled in the past,' says Marty Gordon, 45, from Cedar Rapids. She was seeing Gengler that day because she had a rash on her arm. Gordon — who has been a patient at the clinic for three months — smiles when she says the women here feel like family.

'They help me feel more comfortable and talk through everything from my toe up to my head,' she says.

Insurers benefit, too, when customers make better health decisions

Providers aren't the only ones toying with the idea of population health management and the best way not only to implement it, but also to improve outcomes.

'A lot of experts these days are talking about how the ZIP code where you live is more important than your genetic code,' said Becky Wampler, director of health care sustainability for Wellmark Blue Cross and Blue Shield in Des Moines. 'Is there access to transportation to use? Is it easy to buy healthy foods?'

Individuals with a chronic condition such as diabetes or heart problems make 58 percent to 60 percent of the company's total spending, Wampler said.

'You take that data in aggregate and say, what's causing chronic conditions? Obesity — the rate has increased over the last 30 years over 30 percent. What data do I know about the community to help me solve that?'

There are hundreds of things in a community that can nudge someone to a healthier choice, Wampler added.

So the insurer looked at how it could help people live healthier lives — which in the end can improve the insurer's bottom line — and in late 2016, it announced a new population health management initiative aimed at doing just that.

The Healthy Hometown program gives Iowa communities, schools and workplaces three avenues of evidence-based interventions and tools to choose from.

-- Self assessment — Schools and workplaces can take an online assessment, which in turn will send a report detailing ways to improve health. For example, a school principal may take the assessment and receive recommendations to create a school garden or implement a walking school bus.

-- Project — Cities and towns can apply to implement a project. If chosen, Wellmark would supply the community with experts to help develop a plan, such as how to make cities more pedestrian friendly.

-- Community transformation — Communities can apply to implement a broad improvement strategy over several years. If chosen, Wellmark would supply experts to help develop a plan.

It's currently working with seven communities, Wampler said, and has several more in the hopper.

It's also working with providers to improve population health. Wellmark created an accountable care organization in 2012 — a group of hospitals, physicians and health care providers that work together to provide better coordinated care. The idea behind an ACO is that patients will receive fewer unnecessary services and more preventive care.

There are 16 different participating health care organizations, said Mike Fay, Wellmark's vice president of health networks

The ACO so far resulted in $60 million in savings 2016, Fay said, and more than $115 million in the past five years. The insurer collects data and presents it to member health care organizations on an aggregate level — to see how people are interacting with the health care system, potential gaps in care, the total cost of a Wellmark member and if that person is on their way to developing a chronic condition.

'It doesn't seem like big deal, but a lot of that information sits in an isolated place,' he said. 'It's not aggregated or connected for people to see those kinds of things.'

Finding that individual with a chronic illness and helping prevent him or her from developing a second one is incredibly important, he added. Data shows that an individual with two chronic illnesses cost about three times more each month than a person with only one.

'Value-based care is a journey and one that we're still on,' Fay said. 'The challenge is you just can't keep doing what you're doing. We have to help people transition from one environment to another. Right now, providers feel like they have one foot in two different boats. We're trying to keep the boats from moving not too far apart.'

l Comments: (319) 398-8331; chelsea.keenan@thegazette.com

This story appears in the fourth edition of the Iowa Ideas magazine. Order a free copy here.

A blood pressure cuff at MercyCare Health Partners in Cedar Rapids on Wednesday, July 19, 2017. (Liz Martin/The Gazette)

Marty Gordon of Cedar Rapids laughs during her appointment with nurse practitioner Alindsey Gingler at MercyCare Health Partners in Cedar Rapids on Wednesday, July 19, 2017. 'From my toe up to my head, I can talk to Alindsey about everything,' says Gordon. The social worker at the office has helped arrange for rides for Gordon's appointments. (Liz Martin/The Gazette)

Nurse practitioner Alindsey Gingler reviews medication changes with Bryan Finn of Cedar Rapids during an appointment at MercyCare Health Partners in Cedar Rapids on Wednesday, July 19, 2017. Finn, an Army veteran, had been frustrated with frequent travel to the VA in Iowa City when he found Health Partners. (Liz Martin/The Gazette)

Dr. Monica Meeker listens as Linda Saddoris of Cedar Rapids describes her experiences with medical care at MercyCare Health Partners in Cedar Rapids on Wednesday, July 19, 2017. Saddoris had trouble finding a general practitioner who accepts Medicaid to help manage multiple medical problems, and has seen improvement in her health since coming to the practice a year ago. (Liz Martin/The Gazette)

LPN Stacy Wattleworth reviews data from a patient's blood sugar monitor with Dr. Monica Meeker at MercyCare Health Partners in Cedar Rapids on Wednesday, July 19, 2017. (Liz Martin/The Gazette)

Social worker Deanna Glass calls to arrange a ride for a patient at MercyCare Health Partners in Cedar Rapids on Wednesday, July 19, 2017. Glass is at the practice full-time, which enables the practice to offer a higher level of support for patients. (Liz Martin/The Gazette)

Social worker Deanna Glass (left) confers with LPN Stacy Wattleworth at MercyCare Health Partners in Cedar Rapids on Wednesday, July 19, 2017. Glass is at the practice full-time, which enables the practice to offer a higher level of support for patients. (Liz Martin/The Gazette)

Nurse practitioner Alindsey Gingler listens to a patient at MercyCare Health Partners in Cedar Rapids on Wednesday, July 19, 2017. (Liz Martin/The Gazette)

NP Alindsey Gingler adjusts compression stockings for patient Marty Gordon of Cedar Rapids during an appointment at MercyCare Health Partners in Cedar Rapids on Wednesday, July 19, 2017. Gordon had previously-unaddressed swelling in her legs among other health complications now being addressed. (Liz Martin/The Gazette)

(File photo: Jim Slosiarek/The Gazette)