Population Health: A Nurse-Led Team-Based Model of Care

For the past five years, the population health services organization (PHSO) at an academic medical center has been working to expand care coordination resources to primary care providers and our patients. The catalyst for this expansion was the result of the changing reimbursement landscape from a fee-for-service structure to a value-based care model. This shifted the expectations of primary care providers to an outcomes-based model, with emphasis on total cost of care. Value-based care focuses on reducing avoidable events through comprehensive care planning, improved access, close patient follow-up, measurement of patient outcomes, and the meeting of national quality metrics outlined by the National Accreditation Quality Assurance (NCQA). As Margaret O’Kane, President, NCQA, states, “Population health is a model of care that strives to address patients’ health needs at all points along the care continuum, including the community setting, by increasing patient participation and engagement and targeting interventions.” Knowing that providers cannot do it all, a team-based approach was employed to help their patients get the right care, in the right place, at the right time.
Housed within PHSO is the population health team, consisting of nurses, social workers, advanced practice providers, physicians, medical assistants, care navigators, digital health coaches, nursing, and public health students. The team supports in a myriad of ways seven key programs which include quality for care gap closure and performance tracking, student rotations, utilization management, transition of care, disease management/digital health, complex care management, and in-home provider visits. For each program, nurses are the first touch point, using a risk score methodology to offer patients a menu of resources based on need and patient preference. Those resources may consist of simple reminders of lab and cancer screenings that are overdue, health coaching with concerns escalated to the provider, and/or digital health equipment at home for blood pressure and blood sugar management. Other services, designed for our more complex, vulnerable patients, include post-discharge follow-up education to reinforce discharge instructions, confirmation and coordination of community resources, and performance of medication reconciliation, along with the scheduling of primary care provider appointments and in-home provider visits for more intense care management using an interdisciplinary team dynamic. In addition, and in some ways a benefit of COVID-19 pandemic, when student nurses had to find alternative clinical assignments from the hospital setting, population health provided a robust training ground and continues to engage daily nursing student cohorts in a variety of population health-based learning opportunities.
In summary, over the past five years, our population health nurse-led team has reduced unplanned admissions by approximately 30%, improved blood pressure control by approximately 10%, and improved optimal diabetes care by approximately 18%. Our quality rating has been five starts for our Medicare patients and top 10% for California for our commercial patients. We continue to work on nurse-led initiatives and program development in partnership with leadership, providers, and clinics.