Northwest Physicians Network (NPN) in Washington State has launched a collaborative population health program that has cut hospital admissions by 43 percent, ambulance transports by 47 percent, and emergency department visits by 36 percent.
The program, which integrates clinical teams, community partners, and first responders, has also led to a 44 percent reduction in emergency calls, and a 31 percent reduction in observational hospital stays.
Each year, thousands of individuals in Pierce County call 911 to request emergency services for issues related to heart disease, diabetes, hypertension, and other complex conditions, a press release stated. While some of these calls are emergency situations, others could be better handled in a clinic or physician’s office.
“Unfortunately, more often than not, these patients’ needs far extend the basic services provided by emergency service personnel,” said Bill Barber, battalion chief at West Pierce Fire and Rescue.
“As a result, our resources are overburdened and the patient is stuck in a seemingly endless cycle of 911 calls and hospital visits because their health isn’t actually improving.”
To reduce potentially unnecessary emergency services, NPN partnered with six fire districts in Pierce County, as well as other local medical and community groups. Formed in 2014, the collaborative program requires fire districts to refer patients to NPN if an individual has called 911 more than twice in two months, or more than five times in five months.
NPN, part of Davita Medical Group, then refers patients to case management services that are connected to their primary care, behavioral health provider, or payer. In some cases, NPN will form a wellness team to meet with the patient and determine how to best address their clinical, mental, or substance abuse issues.
Since the start of the population health program, the collaborative has coordinated approximately 750 referrals to health systems and community resources. The program has also brought together 28 community partners that meet on a monthly basis to discuss barriers and change outcomes for patients.
“The success of this program is directly related to the relationships that we’ve formed in our community,” said Melissa Haney, community partnership and behavioral integration manager for NPN.
“This program allowed health care and social services professionals, who may have never worked together before, to join forces in order to provide care that addresses the whole patient.”
NPN worked with Qualis Health to track 184 Medicare patients referred to the program. Qualis Health found that the total reduction of emergency services represents 990 fewer 911 calls and 548 fewer ambulance transports. More than half of the observed patients also experienced improved health outcomes after participating in the program.
Moreover, the evaluation showed that these 184 Medicare patients saved an estimated $7.38 million on hospital visits alone. In Washington state, there are 880,000 Medicare patients, and an estimated 34,703 of those are high utilizers, making these results especially significant.
“The outcomes we unearthed were incredible,” said Meredith Agen, assistant vice president of healthcare analytics at Qualis Health. “The team measured changes for five key metrics over a 12-month period prior to intervention and 12-months post services; the outcomes we found represented a significant volume reduction for a small set of patients.”
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