Successful and sustainable value-based care programs require an ecosystem approach, it takes a village. The ecosystem must be comprehensive from a delivery system perspective and include all organizations providing care, including payers, patients and their care givers as well as human service staff such a social workers staff to assist with housing and others. The ecosystem must also include partners with experience in population health and technology-enabled services. With the rise in population health management, it is becoming clear that organizations taking on risk need more than technology, they need domain expertise and experienced leadership.
Aria Health is the largest healthcare provider in Northeast Philadelphia and lower Bucks County. With three community hospitals, a network of outpatient centers and primary care physicians, Aria upholds a longstanding tradition of bringing advanced medicine and personal care to the many communities it serves. In a recent interview with Aria Health that IDC Health Insights conducted their Chief Operating Officer, Sandy Gomberg shared the following: “What we (Aria Health) learned in our quest for the right technology and the right partners is that it’s as much about the technology as it is about a longitudinal relationship with people who can bring the skill sets for that practice transformation.” Aria Health developed a partnership with Lumeris in 2013 to assist in their transformation to value-based care. Lumeris’ technology-enabled solutions and services provide Aria with the necessary capabilities to support value-based care, including analytics that identify and stratify patients, performance measurements, establish and monitor care plans, conduct campaigns for selected populations, and communicate with individual patients.
Using data from the Lumeris’ platform Aria Health provides its physicians with patient-level data regarding gaps in care. Physicians are able to reinforce the importance of prevention and screenings to patients at the point of care and place orders to close the gaps. Aria Health created a clinical integration team of health coaches, nurse administrators and individuals with advanced analytic skills were hired by Aria. They work at the corporate level and assist physician practices in their transition to value based care. With the assistance of Lumeris, Aria defined the role of the clinical integration team to assist the practices with changing workflows, defining roles and responsibilities, hiring staff, interpreting data and developing action plans for both the coaches and nurse administrators. Aria strongly believes that providing physicians with actionable data at the point of care is critical, and structured the work of the health coaches and nurse care managers to support the delivery of that data.
Aria describes its management strategy for transformation as physician-driven and administratively-led. At this time Aria Health reports that they have successfully realized 80% of their risk opportunity and made significant progress in reducing gaps in care. This is a clear indication that providing physicians with the right tools and data can have a significant positive influence on improving clinical and financial outcomes.