Lutheran Family Health Center Handles Grant Requirements, Boosts Key Quality Measures Through DRVS Expansion

In Brief: Lutheran Family Health Centers (LFHC), one of the country’s largest federally qualified health centers (FQHCs), needed a comprehensive data reporting and analytics solution to satisfy requirements for a new Medicaid grant. The initiative focused on introducing the principals of the patient-centered medical home (PCMH) into graduate medical education for the center’s internal and family medicine residents.

LFHC needed to focus on expanding PCMH principles and identifying the data required for managing patient populations more effectively. The center significantly expanded its use of the web-based Azara DRVS data analytics and reporting platform underlying the Community Health Center Association of New York State’s (CHCANYS) Center for Primary Care Informatics (CPCI) in order to address data needs generated by the Medicaid grant. 

Resulting benefits include:

• System-wide effort to improve care transitions
• Program for identifying and managing high-risk patients
• Enhanced patient panel managementQuality improvement (QI) initiatives for center medical resident

The Story: LFHC is part of Lutheran HealthCare, a Brooklyn, New York system that includes Lutheran Medical System, a 450-bed acute care hospital. The provider network is spread across more than 60 locations, including nine primary sites, 28 school-based health centers and 12 sites that provide services to the homeless. The FQHC offers an array of additional services, including dentistry and behavioral health. It stands among the nation’s largest health centers, supporting 86,000 patients and accommodating more than 600,000 annual visits. The vast patient population, heavy volume of patient encounters and wide array of services demands that the center employ a data analytics and reporting platform capable of extracting and organizing reams of data quickly and efficiently.

“We need something that is actionable on a daily basis,” said William Pagano, M.D., senior vice president, clinical operations at LFHC. “We need something that processes information and gives us the data we need to manage patients and populations.”

As part of its DRVS expansion, LFHC boosted its ability to ensure patients experience a smooth transition from the hospital to the ambulatory care setting. The FQHC houses multiple disparate electronic databases, and Azara pulled the information together while normalizing it, thus generating a comprehensive picture of patients as they move between care environments. Azara and LFHC developed three basic transitions of care reports: a daily admission report, a daily discharge report and a Visiting Planning Report. The latter – an integral component of DRVS - is generated each morning prior to patients’ arrival at the health center sites.

With the admission and discharge reports, each center receives a daily list of patients who were recently admitted to or discharged from Lutheran Medical Center. Pagano said the task of tracking patient admissions and discharges may seem simple, but prior to DRVS, health center staff was mostly unaware of patients’ hospital encounters. Information about admissions and discharges is addressed during each sites’ morning huddles, a daily activity where clinical staff gather to discuss the slate of patients scheduled to visit that day. Special emphasis is placed on patients who have special risk factors, are due for tests, or have other needs that require specific or special attention.

LFHC’s case managers rely on the discharge reports to ensure patients are contacted within 24 hours of hospital discharge in order to be asked a series of questions (known as a CTM-15) that determines how well the patient was prepared for discharge. Questions include whether patients understand why they were admitted to the hospital and any steps they must take to care for themselves post-discharge, such as medication adherence. The case managers bring the reports to the morning huddle. LFHC also uses the discharge reports to schedule patients for follow-up outpatient appointments.

Results are positive: Six months following the DRVS implementation, 30-day hospital readmissions among the center’s Medicaid population dropped from 35 percent to 24 percent.

DRVS helps LFHC stratify risk
Azara also developed and implemented an algorithm for LFHC that assigns a risk score to each patient, allowing the center to stratify patients by a risk classification.

“As part of being a PCMH, you need to manage your high-risk population,” said Pagano.

Health centers such as LFHC can only properly manage high-risk patients if they can identify them, and that has been a long-standing challenge. Financial information from health insurers and other sources that indicate high-risk patients can be difficult to obtain, and once the data is in hand it is often several months old and no longer actionable. The risk stratification system Azara developed with LFHC works like this: Patients get classified as “high,” “moderate,” or “low” risk based on an active diagnosis in one of 11 key categories and whether they have had two or more hospital admissions (inpatient or emergency department) during the previous six-month period. The highest risk patients have more than one risk diagnoses and have made two or more IP/ED trips. Moderate risk patients have one or more than one of 11 risk diagnoses, and low risk patients have none. Risk diagnoses include: asthma, diabetes mellitus, heart failure, hypertension and severe mental illness.

“We use it for stratifying patients so that we know which ones we need to focus our resources on,” said Pagano. “Patients are managed for six-weeks post hospital discharge. The care manager calls them at least once a week for a minimum of six weeks, and community health workers go to a patient’s home if needed.”

Visit planning, panel management and quality improvement reports boost care outcomes
The Visit Planning Report’s gap analysis component provides data specific to demographics and clinical diagnosis. Preventive measures are included, such as a patient’s need for a mammogram or colonoscopy.

“The great thing about it is it’s actionable,” said Pagano. “It’s what that patient needs that day. Care managers cut and paste high-risk gap analysis into the medical notes for the physician. So when the physician sees the patient, the gaps are already incorporated into the note, and that means the doctors don’t have to go looking for them elsewhere.”

The patient panel management report collects data on all resident physicians and their patient panels. The report is key to the to Plan-Do-Study-Act (PDSA) cycling QI initiative used for panel management. The report drills down to the individual provider level, allowing residents to review how well they are managing their patient panels on an array of metrics, such as hemoglobin A1c and blood pressure control. Residents are using the reports to determine which patients need a diabetic foot exam. Prior to the DRVS implementation, providers needed to contact the information technology (IT) and QI staffs to obtain a report; now they need only to open DRVS to view the data. The program helped LFHC boost the rate of completed diabetic foot exams from 11 percent to 42 percent over a six-month period.