Engaging patients and managing population health during a pandemic—and beyond

Excela Health’s value-based performance team shares how the organization’s sound strategy helped close gaps in care during its COVID-19 response and will enable expanded outreach efforts going forward

By and Drusilla R. Emanuel | 3 minute read | August 27, 2020

The COVID-19 pandemic has significantly changed our world. But, for the most part, our value-based performance team has found that our core population health mission and strategy have withstood the pandemic’s test.

At Excela Health, we take a two-pronged approach to managing population health  local management and centralized resources:

  1. Local management – Clinicians, staff and the office team play a key role in delivering services to improve community health. If they have real-time information, they can dynamically shift their outreach and activities to support their unique populations.
  2. Centralized resources – Critical support for these local efforts. Our centralized team provides data and feedback, as well as helps interpret that information, for each site.

Together, they are a powerful combination to demonstrate measurable outcomes, which is essential for success with value-based contracts. Excela Health is based in the greater Pittsburgh area, which is a highly competitive healthcare market. It is a competitive advantage for Excela Health to be able to consistently demonstrate value, and we have proven this by performing above market in shared savings arrangements.

In addition, while we anticipate payers will make some changes, we expect to still be held accountable to risk adjustment scores and certain quality benchmarks. The calendar year 2020 will still be important to those measuring value-based health performance.

We continue to assess our performance against existing measures, and our healthcare providers know where they are in terms of their score and our goals for the year. This is a process we’ve followed for several years and is serving us well, even as we deliver care in different ways during the pandemic.

Engaging patients during a time of crisis

A key part of our value-based health strategy is to engage with patients and deliver messages effectively. Traditionally we have used Phytel Insight and Phytel Coordinate to help engage our patients. While COVID-19 did not change this tenet, the disease certainly changed what our patients needed to hear from us.

For example, we began using telehealth extensively – within one week we had most physicians across the system using it. It enabled us to provide clinical support to patients, whether it was to address COVID-19, chronic disease management, pre-visit planning sessions, other health concerns or even wellness checks.

We have a great social media team and the ability to reach people through our portal solution, but those mechanisms only reach a portion of our patient population. COVID-19 required us to reach every patient who has provided contact information to let them know telehealth is an option for them, as well as recommended safety precautions for any in-person interactions.

We used a campaign through Phytel Coordinate to reach more than 88,000 patients the first week and our second attempt enabled us to reach another 18,600 patients the following week. An ad hoc email campaign enabled us to contact more than 98,000 patients in one day.

Looking ahead: value-based health after COVID-19

Throughout this time, our healthcare providers have proven that they can effectively close gaps in care using telehealth. We anticipate that as physicians become more comfortable with it, they will continue to use telehealth more than they did before the crisis, dependent on payer modifications and program adoption.

This experience has also sparked many conversations with our providers about what we can do differently to reach targeted cohorts of patients. They’re asking new questions about options to reach out to patients that can benefit from disease-based clinics, for example, by identifying cohorts based on diagnoses or last visit dates. We expect both Phytel Outreach and Phytel Coordinate will be important to help find patients who need care as we begin to recover from the crisis.

Being part of an accountable care organization (ACO) has provided a level of collaboration that we wouldn’t have had otherwise. Working with other organizations in the ACO provided us with a better understanding of the current state of the market, how value-based programs might be changing over time and what this period might do to our risk adjustment. These are valuable additional perspectives that were previously unavailable to our team.

While our teams are eager to see community health move beyond the response phase to the recovery phase, we will build upon learnings from this experience. Building on a solid strategy and multiple years of experience with value-based approaches, we have a solid foundation and will continue to grow from this.