How HDAI’s data analytics support is helping an Accountable Care Organization on a collaborative mission
A case study of Buena Vida Y Salud (BVyS)
Our Client
Buena Vida Y Salud (BVyS) stands as a beacon of innovation in healthcare. Formed through a partnership between community physicians and the South Texas Physician Alliance, BVyS is more than just an Accountable Care Organization (ACO) – it’s on a collaborative mission. With a growing footprint across Texas, and now Virginia in 2024, BVyS is rapidly expanding its reach. Boasting a network of 96 dedicated providers, with plans to integrate 12 new practices in 2024, BVyS embodies the belief that independent physician practices can unite to offer coordinated, quality, and affordable care.
The journey of BVyS with Health Data Analytics Institute (HDAI) has been transformative. Within just six months of implementing HDAI’s HealthVision predictive analytics software tool, BVyS has revolutionized its approach to patient care. This strategic partnership has enabled BVyS to significantly reduce the number of Emergency Department (ED) visits and unplanned admissions which is efficient and quality centric.
“It’s amazing what our physicians and nurses have achieved in just 6 months by focusing on patients that needed our attention the most. This level of predictive targeting allowed us to be true to our goal of keeping patients healthy at home.”
– Dr. Sheila M. Magoon, Family Practice
The Challenge
Healthcare is witnessing a significant strain on services, marked by soaring costs and increased utilization for an older and sicker population. To navigate this complex landscape, BVyS needed a strategy that would maintain their high-quality care while also controlling expenses. BVyS’s approach entailed 1) pinpointing specific sub-populations based on predicted future risks of utilization, complication, and developing chronic diseases and 2) deploying tailored interventions that reduce the likelihood of those events happening. The project was also designed to assess the impact of HealthVision within primary care practices in Texas.
Innovative Solution
Supporting Intelligent Decisions To Improve Patient Outcomes
To address the challenge of managing escalating healthcare costs and utilization, BVyS implemented a structured population health management approach, focused on monitoring and predicting costly patient outcomes, such as unplanned hospitalizations, fall related injuries, exacerbation of heart failure or development of sepsis/pneumonia.
The core of this approach lies in the identification and separation of individuals within subpopulations, based on their risk of experiencing negative health events or high healthcare usage. This separation, primarily derived from routinely collected healthcare data and driven by validated predictive models, allows for effective targeting and customization of healthcare interventions. Notably, in most populations, a small percentage falls into the high-risk category, while the majority are distributed in medium- and low-risk groups. The 1,372 patients were segmented into three cohorts, with reliance on HDAI’s mortality, hospice, and unplanned admissions predictors.
- Advanced Illness Care (AIC) – patients at the top 5th percentile at risk for mortality or likelihood of entering hospice
- Complex Care – patients at the top 25th percentile at risk for an unplanned admission
- Rising Risk – patients at the top 25th to 50th percentile at risk for an unplanned admission
This study focused not just on disease-specific outcomes but also on broader utilization outcomes such as hospitalization risk and emergency department visits. The central objective of this case study was to conduct a systematic review and evaluate the efficacy of HDAI’s risk stratification tool in identifying patients at high risk of unplanned admissions within primary care settings, as measured by reduced utilization.
HDAI collaborated with BVyS to enhance its platform, focusing on tracking key value-based metrics critical for assessing quality and outcomes. HDAI’s Care Optimization team of health professionals pinpointed essential data for immediate action: identifying patients needing checkups and screenings, high-risk/highutilization patients requiring interventions, and recently discharged patients for follow-up appointments. BVyS was able to create and distribute effective reports, boosting its productivity, performance, and revenue. Key report features include:
PCP Targeted List
- Ranked by highest risk for an unplanned admissions
- Delivered to physicians with the following expectations
- See patients monthly for the next 6 months
- Reassess if patients remain on the list for a second 6 months cycle
- Review cases monthly
Top Factors
Surfacing contributing factors to predicted risks helped guide conversations around proactively reducing the likelihood of an ED visit, unplanned admission, falls, and more.
Workflow Triggers
Additional interventions included workflow triggers into Transitional Care Management, Chronic Care Management and Remote Patient Management programs for patients that required additional clinical support.
THE RESULTS
Over the 6 months following implementation, the predictions and targeting provided by HealthVision were instrumental in care coordination efforts. The system’s predictions and targeted strategies were pivotal in streamlining patient targeting, leading to a significant and noteworthy decline in unplanned admissions and emergency department (ED) visits. This not only marked a substantial improvement in patient care but also led to a notable reduction in Inpatient costs.
