Objective: Identify programs that improve patient outcomes and reduce utilization.

Purpose: Healthcare changing from fee-for-service to value-based reimbursement models requires care redesign. The health system tasked a nurse practitioner to implement and scale evidence-based, population health programs across the entire health system to improve quality of care and patient outcomes.

Relevance/significance (why): With more than 80% of a person's health outcomes affected by social determinants of health, patient care requires a switch in focus from traditional “clinical care” to a focus on social, economic, and environmental factors. Asynchronous care focused on patient-centered interventions has the potential to improve access to preventive services and positively impact chronic disease outcomes. This shift in care delivery can also reduce resource utilization and lower overall healthcare costs.

Strategy/implementation/methods: Due to the success of a nurse-led, clinic-level population health program, the nurse practitioner was named director of population health and tasked with improving patient outcomes and quality of care across the health system by implementing evidenced-based population health programs. These centralized programs are nurse-led, team-based, and interprofessional in nature and were initiated in individual clinics and then scaled across the health system. The population health programs include transitions of care management (TCM), chronic care management (CCM), community health workers (CHW), social work, eldercare navigation, and a quality program that works collaboratively with patients and payers.

Evaluation/outcomes/results: The population health program is now 30 employees strong and spans inpatient, outpatient, and partners with community-based organizations. The CCM program has enrolled 202 patients. TCM cares for 250 patients monthly; the social care program cares for 150 patients monthly, and the quality program averages care gap work for 3,500 patients monthly. Colorectal cancer screening targeted outreach resulted in 238 patient contacts with 102 external records requested and 21 screenings ordered. Outreach for targeted patients showed a 49% and a 7.6% reduction in readmissions in these patient populations. Systemwide, readmission rates decreased by 2.08%.

Conclusions/implications: The nurse-led, asynchronous population health programs improved outcomes and reduced utilization. Nurses have an opportunity to reshape the delivery system to provide efficient and effective care that addresses upstream barriers to provide care in the least restrictive and least expensive manner.

Jessica Sass DNP, APRN, FNP-C

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