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Driving Community Outcomes

Justin Neece

As market needs continue to stretch the bounds of electronic health record system capabilities, healthcare companies are finding innovative ways to address social determinants of health common in the most at-risk populations.

i2i Population Health

Science is the driving force behind i2i Population Health, a national leader of population health management technology. Since its founding as i2i Systems in 2000, the company has grown to serve more than 300 clients in 35 states. And while their technology is cutting edge, President Justin Neece said data extraction is just the beginning for the Franklin-based company.

"We go through a data analytics process that stratifies patient-level data sets against 150-plus clinical quality measures across 16 national and regional programs such as accountable care organizations, patient-centered medical home, and meaningful use," Neece said.

Patient advocates or care mangers then coordinate care from a clinical level, focusing on patients whose risk factors might include smoking, obesity or chronic diseases. For tobacco users, assistance might come in the form of smoking cessation classes or support groups, while dietary education is often offered for obese patients.

Since i2i's software looks at zip codes by urban markets and classifies populations into food deserts - neighborhoods where fresh, affordable food is scarce - some clients are now bringing food trucks onsite to offer the underserved affordable, fresh food that otherwise might be unavailable. Patients also receive dietary education and tips on how to prepare healthy meals.

Zip Codes & Social Determinants

The company also uses geo tracking to identify social determinants surrounding transportation and housing. "Our clients identify zip codes that look at poverty levels and marry that (data) to show unemployment rates, transportation means, and those who frequently no-show to doctor's appointments," Neece said. As a result, clients sometimes offer free van rides from certain zip codes on specific days to provide access to appointments and group education sessions with a whole-health view.

On average, i2i clients see a 22 percent increase in establishing contact with patients who fall into these social detriment cohorts. "If you're an urban medical system with 50,000 patients or more, a 22 percent increase in the underserved is a significant improvement," Neece said.

Growing with the Industry

While the majority of i2i's 70,000 users represent ambulatory medical sites, the company is now working with payers, as well. BlueCross BlueShield of Tennessee and Amerigroup of Tennessee are among those now using i2i's service to improve outcomes for Medicaid patients.

"Now we're merging clinical data sets with administrative and claims data on the payer side to optimize cost of care," Neece said. "It's not just about driving costs down; it is also improving the quality of care and removing the burden from clinicians' workflow to drive community outcomes."

Rusty Holman, MD

LifePoint Health

Another local company making changes nationwide is LifePoint Health. Chief Medical Officer Rusty Holman, MD, said the Brentwood-based healthcare company began addressing social determinants seven years ago after being selected to participate in the Centers for Medicare and Medicaid Services' Partnership for Patients Initiative as a Hospital Engagement Network.

"One of their goals was to find more meaningful ways to engage patients and families," Holman said. "That was the beginning of our modern quality journey."

Thinking Outside the Box

While addressing patient safety and readmission rates, LifePoint leaders found the answer to improved patient health lay beyond a hospital's walls.

"We found it was more difficult to make improvements as quickly or efficiently for readmissions as we could in the world of patient safety, which happens within the hospital," Holman said. That's because many factors related to readmission are connected to social determinants of health, affordability of care, access to primary care and necessary resources to promote wellness.

"Sometimes patients are making the choice between buying groceries or buying their medications," Holman said. "Housing and nutrition, daily habits and health literacy all are very important factors in determining whether or not someone continues to do well after leaving the hospital, or whether they decline and come back to the Emergency Department."

Community Coalitions

To that end, LifePoint now oversees more than 30 structured community coalitions across the country ... each uniquely different based on community resources and needs and comprised of leaders from local organizations. "A common theme we see across all communities is that resources and agencies traditionally have their own missions and purposes but work independently of one another as opposed to working together," Holman said. LifePoint coalitions are helping to shift that paradigm.

In Tennessee, Livingston Regional Hospital's coalition was established to reduce readmissions when data suggested many return trips to the hospital were preventable. Members also recognized a need for increased education around medications and reconciling long-term prescriptions with drugs prescribed during a hospital stay.

In Lake Havasu City, Ariz., hospital readmission rates fell to under seven percent when the local hospital teamed up with paramedics and home health providers to keep people healthier at home. In rural Selma, Ala., a local cab company joined a group of healthcare providers to help get patients without access to transportation to their medical appointments. Other hospitals have engaged churches, pharmacists, local employers, and support groups to help solve their communities' health challenges, reduce barriers to care, and make medical services, medication and equipment more affordable.

A New Focus

"One of the biggest revelations for us as we try to address more complex problems in healthcare is that it's more important than ever to work with partners and view things as a community," Holman said. "These are community issues rather than healthcare system issues, and that perspective means a great deal in terms of our ability to improve the wellness of a community in general. It's been very gratifying."


i2i Population Health

LifePoint Health


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Access to Care, Barriers to Care, Hospital Readmission, i2i Population Health, Justin Neece, LifePoint Health, Patient Outcomes, Rusty Holman, Social Determinants of Health
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