Case Study

Holistic population health improvement integrating claims and clinical data

Key Highlights

  • Monthly report integrates claims and EHR data for hybrid quality measures to close care gaps and support population health goals
  • 14 Hybrid quality measures tied to state and federal incentive funding
  • 100% Quality pool funding received in 2022
  • Early indications of improved outcomes, including reduced ED utilization
  • Custom reporting reveals underlying correlations between preventive care and other support and specific clinical measures

Oregon-based Advanced Health is a coordinated care organization (CCO) – the state’s version of an accountable care organization (ACO) – that takes an innovative approach to the care of its 26,000 members.

Serving two counties where 14-17% of residents live in poverty, according to U.S. Census data, Advanced Health manages a population with complex medical needs exacerbated by social risk factors.

To meet its population health goals, Advanced Health works to understand the needs of its members from a holistic perspective that includes the barriers they face in accessing health care and managing their health. Healthcare management encompasses a wide range of screenings, referrals, and support, including safe housing, healthy food, dental, psychological and substance abuse services, and more.

The bottom line for Advanced Health: the more they know about their members, the better they can serve them. Close scrutiny of claims and clinical data is needed to satisfy quality improvement goals tied to 14 specific measures of population health and report them to qualify for state and federal incentives.

Challenge: Insights that drive and demonstrate improvement

Claims data is critical in this effort, but by itself, cannot provide the depth of insight that Advanced Health needs to drive and demonstrate improvement to the state.

With a mission built around the transformation of the local health care delivery system with improved integration, access and outcomes, Advanced Health needed an analytics solution as innovative and customized as its goals.

Action: A custom solution from MedInsight that integrates claims and clinical data

Advanced Health partnered with Milliman MedInsight to integrate both claims and clinical data feeds in support of a monthly report used to monitor population health metrics used to drive meaningful interventions for improvement. The report breaks down the performance of each of its three clinics using claims data integrated with extracts from multiple electronic health record (EHR) feeds.

The data is further customized by MedInsight to produce evidence-based measures of where each clinic stands related to specific clinical outcomes, including:

  • Controlling high blood pressure
  • Diabetes HBA1c control
  • Depression screening
  • Alcohol and drug misuse
  • Tobacco recorded status
  • Cigarette prevalence
  • Tobacco prevalence

At the end of the year, the monthly report is also used for reporting the organization’s quality measure performance to the state to qualify for continued funding. To meet state requirements, the population is further stratified by race, ethnicity, language, disability, sexual orientation, and identity as part of a mission to understand and address the correlation between health outcomes and the social determinants of health within marginalized populations.

The mission is both ambitious and groundbreaking and relies on MedInsight VBC analytics and integrated clinical data feeds that provide Advanced Health with customized data for measuring and demonstrating progress to the state.

Results: Reporting that shows evidence-based results of success and provides clinics with insight into care gaps

In addition to demonstrating specific, evidence-based results of its success, the reporting also enables Advanced Health to provide each of its clinics with insight into specific care gaps – a data solution that provides both a gauge of the organization’s success and a window into the potential opportunities to do more.

“It really all fits together,” says Amanda McCarthy, Director of Social Determinants of Health for Advanced Health. “When we know who our membership is, we can serve them better. Historically, we had claims data that was our number one data source, and it was just not as enlightening as some of the clinical data that we receive through the electronic health record process.”

The clinical data integration results in customized reporting that can reveal underlying correlations between the preventive care and other support and specific clinical measures. For example, Advanced Health can track year-over-year effects of targeted interventions and care management on health issues like diabetes and high blood pressure control.

“We are able, with that addition, to really identify members who might need interpreter services through the addition of social determinants of health screenings and referrals,” McCarthy says. “Or this member is more likely to show up in the emergency room with asthma exacerbation because they live in a place that has mold, or they don’t live in a shelter at all.”

That deeper understanding provides Advanced Health with the tools and insights needed to successfully participate and drive the quality metrics as well as improve health outcomes for members. In 2022, Advanced Health qualified for 100% of available incentive funding by demonstrating improvement in 11 of 14 quality measures.

There are other early indications of improved population health outcomes, like a downward trend in ED utilization, though McCarthy notes that other factors, including COVID and public health messaging may have also played a role.

At the same time, she said, data-driven decision making powered by MedInsight analytics is helping the organization identify where to invest in improving care. “What we do know is that when Advanced Health looks at ways to be innovative in the space of health outcomes, we start with understanding the prevalence of those social risk factors where we can,” she said.

McCarthy hopes to build on MedInsight support as the program evolves. Next steps include the use of the MedInsight portal to enable providers in each of three clinics to see their specific performance and identify opportunities for further improvement. Leveraging the real time data capability of EHR data, McCarthy and Advanced Health plan to ramp up the organization’s ability to get data into the hands of its providers faster.

“With that performance update on demand whenever they want it, it’s going to really help drive those quality initiatives at the clinic level,” McCarthy said.

About Advanced Health

Advanced Health is a locally owned and operated coordinated care organization (CCO) serving all communities in Coos and Curry counties in the state of Oregon, connecting members to high quality medical, dental, behavioral health, and substance use treatment through local collaboration and innovation.

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