Integrating Care for Population Management: An Example from One Health Care System

The health of a population is impacted by many factors and one of the factors is medical care.  Health care systems or hospitals provide the most intense medical services and these services  are segregated according  to diseases or conditions.  The segregation of patients based on disease or conditions creates populations of patients inside the health care system.  The management of patient populations are incentivized from federal funds associated with the electronic medical record.  However, to effectively manage populations of patients with the electronic medical  record, health care systems need to transform systems of care delivery by providing quality improvement education and by integrating clinical, informatics, operational and financial systems.   In 2009, Texas Children’s Hospital started a new culture of quality by educating health care professionals (Baylor College of Medicine faculty included) on the science of improvement and in 2011 initiated a structure to manage populations of patients inside the health care system.  The initiative transformed care delivery by creating accountable clinical teams, structure , processes, and easy- to- access data for clinicians to manage populations of patients.   The results demonstrate an organization structure that uses data to define clinically meaningful populations and to regularly make population-specific improvements. For example, the Asthma Care Process Team uncovered,  through the routine use of the data, that 68% of the asthma patients were receiving chest X-rays.   The Asthma Care Process Team shared the data with groups of ordering physicians and within just 1.5 months the number of chest X-rays that were determined not clinically relevant by the ordering physicians were reduced by 15%. Additional Care Process Teams have been added such as. pneumonia, diabetes, appendectomy, spine surgery,  and cleft palate surgery.  Other organizations will realize the importance of transforming care delivery systems and understand  the framework  used at Texas Children’s Hospital.