From the 2019 HVPAA National Conference
Dr. Michael Kiritsy (LifeBridge Health), Ms. Tiffany Wandy (LifeBridge Health), Dr. Jonathan Ringo (LifeBridge Health), Mr. Jonathan Moles (LifeBridge Health), Dr. Daniel Durand (LifeBridge Health)
Patient engagement is critical to high-quality care. For that reason, health systems across the nation are continually trying to improve with regard to “activating” their patients. Since primary care providers are often the “quarterbacks” in managing the care for patients, LifeBridge Health (LBH) attempted to devise a way to more directly connect patients with these providers. Moreover, effective primary care helps keeps patients healthy and prevents costly hospital and emergency department visits.
LifeLink is an innovative approach that aligns value-based care with fee-for-service payment models. LifeLink is the LifeBridge Health contact center that is based in Manila, Philippines, and is staffed 24/7 by nurses with excellent English-speaking skills.
Beginning in 2016, LifeBridge Health (LBH), in collaboration with the LifeLink, has conducted yearly Medicare patient outreach campaigns. These campaigns were based on patients of Medicare age identified through our hospital EMR data. Any patient of Medicare age was targeted for outreach. The primary goals were to increase visits to LifeBridge primary care providers, “activate” patients to engage in their healthcare, conduct telephonic fall-risk screenings, outreach to diabetic patients with a high HbA1c, and other activities.
LBH sought to understand the populations of those who were contacted (engaged) compared to those who were not contacted (unengaged) in an effort to further refine outreach strategies and improve health outcomes.
We analyzed the call log data from all three years of our outreach campaigns. We identified unique patients who were contacted during this time period and classified each log entry as to whether the patient was engaged or not. In order to better understand these patients, we matched these patients back to our ACO data and analyzed their demographics and claims data. We examined differences total cost of care in the year they were first contacted, demographics information, and chronic diseases based on those we were able to match to CMS claims data. A two-sample t-test was performed to assess for any differences in age or cost in our population, and Chi-square tests with Yates’ correction were performed for detecting gender and disease rate differences between the groups.
Our outreach program contacted 36,297 unique Medicare patients over three years. 14.52% (5,271) of patients engaged on the first phone call. Overall demographics were not meaningfully different between the groups, although the average age of engaged patients was higher than the age of unengaged patients (p=0.002), as seen in Table 1. When comparing chronic disease data, significant differences in Diabetes, dementia, chronic kidney disease, and psychiatric illness were detected between those who were engaged and those who were not. Rates of hypertension, heart failure, cancer, COPD, and atrial fibrillation were not significantly different between the groups. Overall cost trended toward being less ($10,723.01 vs. $11,669.60) between the groups (p=0.07).
The three differences in the two populations we detected were that engaged patients are lower cost, have more chronic illnesses, and have lower rates of dementia and psychiatric illnesses.
The data gathered on the patients contacted and successfully engaged provides valuable insights into the Medicare patient population we care for. By understanding the profile of patients who are more likely to engage compared to those who are not, we can further refine our outreach techniques to aid us in improving the overall health of the population and lowering healthcare costs.