Value-based care aims to improve care coordination and the relationship between a personal doctor and patient. Montgomery County Memorial Hospital External Site (MCMH), in Red Oak, Iowa, has a reputation for being a regional leader particularly by improving not only patient access to care, but quality, too.
Accountable care organizations (ACOs) are contractual agreements that health systems, hospitals and primary care doctors have with Wellmark to achieve certain quality and cost performance targets. The targets are designed to create better coordinated care, improve patient health, reduce the ever-increasing rate of health care cost trend, and ultimately lower the total cost of care for employers.
To get a 360-degree view of a patient, including other doctors or specialists visited, treatments received and drugs prescribed, MCMH participates in Wellmark Blue Cross and Blue Shield's accountable care organizations (ACOs). Wellmark shifted to this model in 2012, and MCMH began participating in 2016. To help ACOs like MCMH reach certain performance targets, Wellmark provides data and analytics about each ACO-attributed member to give a 360-degree view of the member’s health.
“Working with Wellmark as a partner through the ACO agreement, we can effectively locate patients who have persistent health problems, or target those who move from one risk status to another,” says Ron Kloewer, chief information officer and director of campus development at the hospital. “For example, it is too common for a patient to have one chronic disease, but over time, develop another. Wellmark provides data that helps us identify patients who are moving toward increasing level of medical risk.”
Meeting patients where they are
The communities surrounding MCMH have fairly low health rankings, and patients primarily struggle with chronic conditions like diabetes, heart disease and chronic obstructive pulmonary disease (COPD).
“When you live in a rural community and you’re miles from the nearest hospital, or you have limited mobility, it’s hard to feel connected,” says Kloewer. “It’s critical to stay in touch with these patients, so we started looking into how to make this happen.”
To ease a potentially difficult transition out of the hospital for these patients, MCMH introduced in-home biometric monitoring Opens in a new window. “This is an initiative that has grown out of our Population Health Program External Site, and is in sync with the accountable care organization (ACO) agreement with Wellmark,” says Kloewer. “It’s a way to improve the health of a population while keeping a close eye on those with chronic needs.”
For patients in this program, MCMH issues a tablet or smartphone and a WIFI hot spot if internet access is a problem. On the device, a pre-loaded app helps patients interact with hospital nurse case managers, who monitor the app dashboard regularly. Depending on a patient's needs, a Bluetooth scale, blood pressure cuff, pulse oximeters or glucose monitors can be provided, too.
Delivering on the data with Montgomery County Memorial Hospital
Other patients may find that access to prompt care is an issue in rural areas. Enter the Heartland Mobile Health Unit that provides primary care to the areas in and around Red Oak. The mobile health unit is a full service clinic that's usually staffed by a doctor and two nurses who have access to electronic health records. The mobile unit is able to serve smaller communities that are often at a disadvantage when it comes to care. “They aren’t large enough to support their own, stand-alone clinic. It’s simply cost prohibitive. Often, they are left with no other choice but to wait to receive care, often in an emergency setting, when their problems become severe,” says Kloewer.
The data is in the details
The response to the mobile health unit has been overwhelmingly positive. "We have a 95 percent top-box patient satisfaction score,” says Kloewer, which means 95 percent of patients rated the mobile clinic at a 9 or 10 on a 10-point scale.
Since its inception in November 2014, the mobile unit has resulted in an 83 percent reduction of emergency visits for the flu. According to Kloewer, this is because they are delivering care in the right places and at the right times. And, it's making a big difference in the way local residents receive care and get healthy.
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