How automation helped engage patients, close gaps in care

Loudoun Medical Group delivers targeted outreach and exceeds value-based care quality metrics

By | 2 minute read | November 14, 2019

According to the National Center for Chronic Disease Prevention and Health Promotion, six in ten adults in the U.S. have a chronic disease, and four in ten adults have two or more.1 Patients with multiple chronic conditions are more complex, harder to manage, and experience worse health outcomes.  They also require more healthcare resources and experience high out-of-pocket expenses. Physician practices are working to identify and engage these patients in their care for better outcomes.

“For the most part, our patients are like the rest of the nation,” Loudoun Medical Group Quality Assurance Director Clara McAuley-Nussbaum said. “We have a lot of diabetic patients. We have a lot of hypertensive patients. We have high-risk patients with comorbidities. So, our goals would be to identify and treat our chronic patients as well as prevent disease states from starting or worsening.”

These goals align with a broader mission to meet and exceed quality metrics, demonstrating performance to payers. But finding patients and delivering messages specific to their care is a time-consuming proposition. It is especially difficult to engage patients and effectively demonstrate performance across Loudoun Medical Group’s 120 locations, 350 providers, multiple EMRs and value-based relationships with payers.

“With about 100,000 lives to manage, we knew that it was going to be impossible to physically contact patients, either within our staff or within the practices,” McAuley-Nussbaum said. “We knew we needed an automated method for outreach for preventive and chronic conditions.”

Using IBM® Phytel® Outreach, Loudoun Medical Group contacts patients using 200 protocols for adult and pediatric preventive and chronic care needs. The automation saves significant amounts of time and delivers additional revenue.

“What would take one full-time population health staff member one week to complete was being handled in the course of one day of calls by an automated system. And that was for one payer alone…It’s remarkable,” McAuley-Nussbaum said. “Using IBM Phytel Outreach, Loudoun Medical Group was able to outreach our diabetics and have our diabetics come in for visits, resulting in an additional $192,000 in revenue.”

McAuley-Nussbaum shares the story of a patient and his journey with diabetes:

“Our care coordinators do a magnificent job outreaching patients and continuing to provide support. So, we had a patient who had a high A1c value. He couldn’t afford his medications…He was considered polypharmacy, so he was on 12 different medications. He smoked. He had a high BMI. And one of the things that were missing in his world was support.

So, initially through [IBM Phytel Outreach], then being seen at the practice level and the practice referring this patient to care coordination, we were able to decrease A1c values, get him into a smoking cessation program, get him from 12 to four medications and overall improve his quality of life.  

And we may never have captured that patient because this was someone who had not been seen in over a year, if Outreach hadn’t targeted and gotten the right patient to show up at the right time and receive the care he needed.”

Learn more about how Loudoun Medical Group has consistently achieved high-quality scores



  1. CDC

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