Overview

The Solution

To effectively manage individuals across urban, migrant and rural settings, Health Partners needed a comprehensive population health management platform that could integrate clinical, behavioral health, and dental, while also supporting value-based 
performance for reimbursement. The organization required a centralized data reporting solution that could not only track clinical quality metrics but also streamline workflows, enhance coordination, and close critical care gaps.

To achieve their goals, Health Partners chose Azara Healthcare’s DRVS population health platform, together with its Patient Visit Planning (PVP) tool.

With Azara DRVS and the PVP, Health Partners set clear goals for improvement, including:

• Enhance care management for chronic conditions such as persistent asthma, COPD, and hypertension by tracking patient outcomes through custom registries.
• Improve workflow efficiency by reducing reliance on unstructured EHR data, ensuring care opportunities were addressed during each patient visit.
• Optimize the referral process by leveraging the DRVS Referral Management module to track and follow up on patient referrals efficiently.
• Meet value-based performance measures by providing actionable insights that allowed the organization to track and manage quality measures tied to state and federal reimbursements.

Utilizing Azara’s DRVS platform, Health Partners care teams could orchestrate all available patient information into one unified dashboard, allowing them to gain a comprehensive understanding of each patient’s care history, health conditions and treatment plans. 

With the PVP tool, often referred to as the “huddle report,” teams could easily track encounters and interventions, monitor progress, and ensure no care opportunities were missed. The centralized dashboard gave Health Partners’ care teams a comprehensive view 
of patient data, enabling timely interventions across their diverse patient population.

The Results

Following implementation of the DRVS platform, Health Partners achieved several impactful improvements, including:

1. Leading the Nation in Depression Remission:
In 2022, HPWO set out to improve their performance in the UDS Depression Remission measure. Through the use of the PVP, 
measure monitoring and support from behavioral health teams, HPWO  saw a 16% improvement in performance from 2022 to 2023. With an ending measure performance of 25%, they exceeded the national average by 11% according to UDS Clinical Quality Measures 2023.

2. Transforming Asthma Management through Community Collaboration:
Leveraging Azara DRVS for community-centered interventions, Health Partners significantly improved the number of patients with a documented Asthma Action Plan and achieved a 5.8-point increase in average Asthma Control Test (ACT) scores over the past year for the asthma management program within their school-based program. Through a partnership with Toledo Public Schools, DRVS supports in-school and at-home visits by nurse practitioners and community health workers, while Monthly Asthma Care Effectiveness Reports track ACT improvements and asthma-related school absences.

3. Improving Early Interventions in Chronic Disease:
Integration of DRVS alerts enabled improved management of chronic conditions including hypertension and metabolic monitoring for antipsychotic users. Customization of existing alerts enabled Health Partners to meet their specific needs. For example, configured alerts flagged children with high BMI for A1c testing, leading to early identification and intervention for pre-diabetes. 

4. Expanding Hepatitis C Screening:
Shifting from baby boomer-only alerts to universal screenings, Health Partners saw significant increases in Hepatitis C screenings across multiple sites, reaching up to 90% screening completion in some locations.

Utilization of Azara DRVS supports Health Partners' value-based initiatives by offering ready-to-use, adaptable metrics that enable seamless tracking of quality improvements across all patient populations. 

Sustained Success and Future Innovations

Building on their success, Health Partners has continued to see significant improvements in asthma care management. Creating a custom action alert within the PVP, in conjunction with Azara’s Transitions of Care module, Health Partners is able to address overdue interventions at the point of care, reducing the likelihood of asthma-related hospitalizations. 

Additionally, Health Partners has built a custom ‘Registry Data Element’ called “First Line Asthma Therapy RX” to flag patients with low ACT scores, enabling more targeted medication interventions and timely support. Looking ahead, Health Partners plans to further refine these tools, continuing to improve asthma management and integrate behavioral and non-clinical data into their care planning, enabling a more holistic approach to addressing the unique needs of their underserved communities.

“We have been on DRVS for 5 years now and continue to use it in our daily workflows. We value how flexible DRVS is and the ability to customize our data and meet the needs of our diverse population. For us, DRVS has been a lasting solution and something that we will continue to use as DRVS evolves with us and allows us to meet a variety of internal and external needs”

- Jennifer McCloskey, Chief Quality Officer at Health Partners of Western Ohio