What challenges or gaps in care are you focused on?
At Independent Health we are working to improve the health and wellness of our members. One key area of focus is our Medicare population as well as underserved communities in and around Buffalo, NY. We’ve established the Care For You program which provides complex care at home of members with multiple chronic conditions, with the aim of improving health outcomes, increasing access to care, and enhancing their quality of life. This innovative approach to care is unique in the Buffalo area and we are quickly building on what is working. Care For You involves assigning individual clinicians to each patient, visiting them in their homes, creating personalized care plans, and offering them direct access to the various health disciplines within the Care For You program. To ensure the success of this approach, we work closely with the patients’ primary care physician and caregivers to identify and address any barriers to care. This may include providing education and resources to patients and caregivers, access to medical equipment and supplies, and partnering with community organizations to address social determinants of health.
What initiatives are you currently spearheading to improve health?
Congestive Heart Failure (CHF) is a leading cause locally of hospitalizations. One of our top initiatives is to target CHF through a new disease management program under the auspices of Care For You. By identifying and managing CHF patients, we can improve patient outcomes and quality of life, promote preventative care and better control healthcare costs. Through the Care For You program we can provide patients with education and resources to manage their condition, such as medication management, lifestyle changes, regular follow-up appointments, and symptom tracking. We may also leverage technology to monitor patients remotely and use telehealth to allow patients to consult with healthcare providers from the comfort of their homes. On the preventative side, we can promote healthy behaviors and lifestyles through community outreach and education campaigns. We also plan to move into acute care as part of our Advanced Care For You program. This will help to prevent hospital readmissions but also brings with it some interesting technology challenges.
What necessary collaborations/partnerships have you established within and/or outside of your organization in developing your initiatives?
Perhaps the most critical partnership for our Care For You program is with the primary care physicians. Without their absolute support it would be difficult to successfully engage with their patients who are our members. We also partner with other providers ranging from 24×7 phone-based nurses to technicians who can support the patient’s telemedicine experience in their home. For medical technology we partner with Brook Health for their remote patient monitoring solution and corresponding medical devices such as scales, pulse oximeters and blood pressure cuffs. We use a local IT provider for the setup and support of the cloud native infrastructure and the laptops, tablets and mobile devices. We pay close attention to the market to understand what innovations are being explored and look for opportunities to experiment. You will frequently find us on calls with medical technology innovators to hear how we might improve the patient or clinician experience.
What is your measurement criteria for success/or current measurable improvements have you realized from the initiative?
We are laser focused on improving health outcomes and increasing access to care. A key metric for us is a reduction in hospital admissions. We are also able to look at medical cost by line of business and see reductions there. As the patients do not see any increased costs for the Care For You program we have seen improved member satisfaction as well as increased engagement as we guide them to various offerings. Outcomes for members enrolled in the program include a 54% reduction in preventable hospital admissions and a 45% reduction in readmissions. And 97 percent of members enrolled in the Care For You program were satisfied with the care and services provided and would recommend it to others.
What gives your hope for the future in health care?
I believe our Care For You program proves that not-for-profit, community-based health plans, are well positioned to address the social determinants of health. With the ability to creatively experiment with new care models and a personal touch we will see improved health outcomes and greater access to care in underserved communities.
Vice President, IT Service Operations