Data Drives Better PCMH Outcomes: A Case Study of Strategic Analytics in Colorado Springs

Colorado Springs Health Partners is a physician-owned multispecialty practice that has served the Pike’s Peak community for more than 65 years. Their physicians number about 135 in more than 20 medical specialties. Each year they see more than 100,000 patients across their 10 sites that include full service diagnostics, ambulatory surgery services, urgent care, hospitalist medicine, health management, a sleep center and a pharmacy.

CSHP is grounded in primary care and committed to advancing their patient centered medical home (PCMH)—Patient Care Compass, says CEO Debbie Chandler. Since 2009, the group’s primary care sites have achieved the highest level possible (Level III) of PCMH recognition by the National Committee for Quality Assurance. They also are eight of the 73 practices selected in Colorado for the Centers for Medicare &  Medicaid Services-sponsored Comprehensive Primary Care Initiative (CPCI) pilot and are a key provider participant in the Central Colorado Community Care Medicaid RCCO project.

Defining the goal

Achieving PCMH excellence started with a dedication to and investment in data and strategic analytics, according to Chandler. Data and analytics were at the core of CSHP’s quest in 2012 to transform care delivery, improve the quality and coordination of patient care and reduce costs for patients and their communities. They needed to find a software solution to assist them in the transition to value-based care. So the practice set out to find a system to digest raw clinical, operational and financial data, and understand, assemble and standardize the content to create data-rich, user friendly reports.

A team of physicians, administrative and IT leaders explored the vendor marketplace seeking a solution to unite their EMR, patient management and claims data and create a longitudinal view of individual patients as well as their population. The choice to anchor the program was clear: Optum One. The system was installed late in 2012 and went live in early 2013. Since then, the results have been measurable—and impressive. After one year, the practice achieved an incremental target of 70 percent control of its hypertensive patients. Improvements ranged from 3.5 percent to 19.8 percent among the clinics. Data revealed variation among the CSHP sites so a plan was initiated to engage all clinical teams to raise the bar.

How it works

Optum One is the backbone of the strategy. Based on cloud-based software as a service, it analyzes, compares and benchmarks data and information, generating intelligent, data-rich and user-friendly reports. It assists in managing populations and improving wellness, comparing practice to practice via a robust database of 40 million patients from across the country.

In Colorado Springs, the solution unites cost and coding data from the billing system and patient care data from their EMR. Two clinical data specialists, an RN and a PhD, make up the clinical innovation department that manages reporting delivered to physicians and care givers. 

The first project focuses on two high-risk conditions: hypertension and diabetes, Chandler says. “We needed to understand the clinical, demographic and financial characteristics of our at-risk populations to be able to manage them over time,” she says.

Every month, a new snapshot of data emerges for clinicians to act on. Nurses and care coordinators learn from the data, drilling down into individual patients, looking for gaps in care and reaching out to bring them into the office or reestablish healthy patterns. They call patients in for blood pressure checks, using the opportunity as an educational and reinforcing moment. RN navigators reach out to patients recently discharged from the hospital or the emergency department to be sure they are executing on orders and therapy and taking their meds. They also coordinate care transitions via well-defined processes.

While the practice has shown good success among their hypertensive patients—with 72 to 82 percent rates of control, the diabetes initiative has proven more challenging. CSHP’s initial rate of control in its diabetes population of 75 percent has yet to be met but they are working hard to get there, Chandler says.

Cheers from caregivers

Across the board, response from the care team to strategic analytics has been excellent. Nurses, care coordinators, nurse navigators, population health specialists and physicians are finding value and spreading word in the community. “They all have really embraced it,” Chandler says.

Patients have seen a difference in care too, and have made it known. “Patient reaction has been pretty good. We are engaging our patients more and doing a good job reaching out. We are adjusting meds and offering more education,” she says. “These reachouts and visits show we care. It all helps our results.”

Payers also are taking notice. “We market to our payers that we are benchmarking our data against the Mayo Clinic and many, many other clinical leaders,” Chandler says. “By showing our effectiveness in patient wellness and PCMH, we identify the value of our practice over others.”

the bottom line?

Coupled with improvements in patient care and outcomes are CSHP’s impressive cost savings. “We have looked at the data and we are absolutely saving money,” Chandler says. “The data show how well we are doing—with costs averaging 12 to 30 percent lower than the rest of the facilities in the CPCI pilot. In dollars, that means about $2 million in documented savings in our management of 5,000 patients.” Another pilot showed PCMH savings of $5 million for a population of 5,000 to 6,000 patients. Savings have come largely from reduced costs of imaging exams and hospital costs, she notes.

Quality is excellent too, with CSHP ranking in the top 10 in every calculation when compared to other practices utilizing Optum One (Anceta Collaborative). In hypertension and diabetes management, CSHP has consistently ranked in the top eight of all participating groups.

Into the future

The more they learn, the more CSHP seeks to expand their knowledge, Chandler says. They have much more to explore. One goal is moving into real-time data analytics, offering information at the point of care. “That is someday. Soon, I hope. Overall, we are very pleased,” she says. “This is the right thing to do. I see it as very important for practice administrators to embrace [analytics] and educate physicians why this is important.

For facilities launching into a similar project, Chandler recommends taking it slow, one step at a time. “Keep it simple. Keep the data simple and give people time to get used to it.”

She calls it a true commitment but well worth the effort. “If you want to be on the cutting edge, you need to invest to improve healthcare and continue to drive down costs. Physicians need to take the lead. Patients listen to doctors and doctors listen to doctors. Having the systems, technology and information and being able to use that to refine care and reduce cost is the future of healthcare.”