How HDAI’s data analytics support is helping a large urban Accountable Care Organization
A case study of Houston Methodist Coordinated Care
Profile
Houston Methodist Coordinated Care (HMCC) is a Medicare Shared Savings Program ACO, led by doctors affiliated with Houston Methodist and the community, with 50,800 attributed beneficiaries and more than 300 primary care physicians, serving the Houston metro area and taking both upside and downside financial risk in this value-based care program. The Health Data Analytics Institute (HDAI) has offered HMCC predictive analytics support through its Health Vision platform for nearly two years.
“Before we started working with HDAI, I had no insight into the clinical or cost performance of potential new physicians to participate in our ACO. With this data, we can better see how much it costs for each doctor to take care of their patients. And HDAI has identified quality physicians in the market that we didn’t even know about.”
–Dr. Julia Andrieni, CEO and President, Houston Methodist Coordinated Care and SVP Population Health and Primary Care, Houston Methodist
Objectives
HMCC uses HDAI data support for a number of key strategic purposes:
- Recruiting primary care physicians with sizable Medicare patient populations who have the best clinical and cost performance. Using HDAI data analytics, HMCC identified and signed on five new physician groups serving more than 2,500 Medicare (MSSP) beneficiaries.
- Measuring the performance of individual nurses in preventing avoidable emergency department and hospital admissions, and using that data for education.
- Identifying post-acute skilled nursing facilities with the lowest rates of patients being readmitted to the hospital.
- Identifying patients at high risk of an ED visit or unplanned admission who could benefit from nurse outreach and possible enrollment into HMCC’s post-discharge, complex care, advanced illness, or palliative care programs.
- Evaluating how well providers are managing cardiology patients in Houston Methodist’s Medicare bundled-payment program.
- In the future, identifying specialist physicians with the best clinical and cost performance for recruitment into a high-value specialist network.
“We’re always looking for ways to figure out which patients we need to reach out to first. The HDAI data have been helpful in identifying high-risk patients whom we can impact, such as patients sitting at home who haven’t been to the hospital or ED yet but who are at risk for an unplanned admission.”
–Agnes Kats, RN, manager, value-based care, Houston Methodist Coordinated Care
A patient success story
Based on HDAI data, Agnes Kats, MHL, BSN, RN, CCM , HMCC’s value-based care manager, identified an attributed beneficiary who seemed appropriate for HMCC’s complex care program but who had no previous contact with HMCC providers. The HDAI algorithm listed the man in the top decile of risk for an unplanned admission and/or ED visit in the next 90 days.
A nurse called the man’s spouse, who reported feeling overwhelmed by his erratic behavior and refusal to take his medications. The nurse educated the spouse on available resources and made a referral to outpatient behavioral services and a neuropsychiatry appointment. “Hopefully we can get the patient to a more stable place and avoid unnecessary hospital utilization,” Kats said.
Key measure of success
“We’ve always achieved shared savings in our ACO program, but this will probably be our best year,” says Dr. Julia Andrieni, HMCC’s president and CEO. “HDAI is part of that. They help us improve care for our patients, and if you provide better care, return on investment follows.”
Fitting data analytics into provider workflow
HDAI generates user-friendly spreadsheets on the patients and providers, and HMCC team leaders can easily sort the data. The physician and nursing team leaders then share and discuss the data with team members and use it to drive strategy. “The leaders and their teams love it because they have more timely insight they never had before,” Andrieni says.
For the nursing team, Kats makes HDAI’s information on patient risk levels available to her staff, who also can access the data themselves on HDAI’s Health Vision online platform. HDAI is integrating the predictive analytics data into Houston Methodist’s electronic health record.
The HDAI data tools are more useful than previous systems HMCC used because the data include actionable information on patients’ specific conditions and past medical visits, rather than just ranking patients as high, medium, or low risk. “That helps us inform future strategies with patients,” Kats says.
Working relationship with HDAI
HMCC team leaders meet with HDAI staff at least once a month to discuss their ongoing data initiatives as well as new issues. “I’m impressed with how HDAI is pushing the boundaries in data analytics,” Andrieni says. “Something about their supportive team dynamics brings out the best in our team. I’ve never heard them say, ‘We can’t do that.”
HDAI’s data sources and predictive analytics tools
HDAI pulls patient-level claims from Medicare’s Beneficiary Claims API, then computes dozens of predictions for each patient using weekly updates. It also uses other data sources including electronic health records. HDAI builds hundreds of predictive models to map the intersections of medical conditions, outcomes, and costs across all care settings. It offers clients data via its web-based Health Vision platform and customized reports.
The HDAI team
Boston-based Health Data Analytics Institute is a care optimization company partnering with leading health systems, ACOs, and payers to improve care delivery and population health, enabled by advanced predictive analytics. The team includes experts in health analytics, clinical operations, care management, data science and big data.
