Over the past year, Methodist Hospital has been building a Population Health
Model. Population Health management is no longer a buzzword; it is a key
concept to taking care of the whole patient. Population Health has been
defined as “the improvement of health outcomes of a group of individuals.”
The goal is to have appropriate care coordination with a network of providers
that work together to ensure positive outcomes and to provide the best
care at the lowest cost.
The overall goals of Population Health include reducing readmissions, reducing
repeat or unnecessary emergency room visits, reducing unnecessary care,
managing the care of a population for better outcomes and reducing costs
for patients and the health system.
“Population Health requires multiple sources working together to
provide the highest quality care to our patients," said Stephanie
Jenkins, MHA, Vice President, Methodist Physician Group. “For success,
it must have provider champions, administrative support and employee buy-in.
This is not just an outpatient endeavor. This involves our inpatient team,
emergency room, case management, information systems and many others.
Due to the improved coordination of care among other changes over the
last six months, we are beginning to see improvements in our data in both
the inpatient and outpatient setting.”
Jenkins noted, “On the outpatient side, we have seen an improvement
in our quality scores. In 2015, the star rating with some commercial payors
was below two (2) and now for 2017 our star rating is as high as 4.88
with the same health plans—the highest we have ever been scored.
The highest possible score is five (5).
“We have also been able to avoid a 2% penalty in Medicare reimbursement
for the calendar year 2018 due to our improved quality. This will be the
first time in more than three years that we have been able to avoid a penalty.
“In regard to the inpatient data, we have seen a marked downward
trend in readmissions over the last quarter. This includes readmissions
for heart failure, COPD, stroke and others. By looking at the patient
as a whole and keeping them at the center of our focus, we are seeing
improved outcomes and success in our efforts.”
Methodist Physician Group’s journey with Population Health began
in November 2015. A pilot program was started with one Registered Nurse
who worked with one family practice office. This began the coordination
of care with discharged patients to help reduce their risk of readmission
and close any care gaps. Her involvement led to improved patient understanding
of their condition, co-morbidities, treatment and health goals.
Registered Nurses have been assigned as Care Coordinators to each of Methodist
Hospital’s family practice providers and residents. Their primary
role includes following up with patients discharged from the emergency
room or Hospital, following up with high risk patients, scheduling wellness
visits and working with specific high risk populations.
They make phone calls to the patients within 48 hours of discharge and
ensure patients understand their discharge instructions, have the medications
they need, coordinate any outpatient follow up care needed, provide education
and alert the primary care provider to any changes along the way. The
idea is to have someone at the center of the patient’s care, helping
them to navigate their healthcare and ensuring they understand their conditions.
Jenkins continued, “As an industry, healthcare is under constant
pressure to continuously improve. Commercial and government payors expect
value and quality over volume. This shift to value-based reimbursement
requires health systems and medical groups to become creative in how they
deliver care. The focus can no longer be on the number of patients through
the door, but instead must be on how we care for those patients, the outcomes
they achieve through our care and keeping them healthy in the long-term.”
For questions regarding this press release, please contact Brandi L. Schwartz at