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CoxHealth uses the power of analytics to improve their care management program

by CoxHealth

Published on 1/11/2023

With an estimated 10,000 people turning 65 every day, the Medicare population is expected to grow as life expectancy increases.1 Providing appropriate healthcare management is crucial for clinicians in their efforts to improve overall patient care and elevate their patients’ quality of life.

Located in southwest Missouri, CoxHealth is a community-owned, not-for-profit health system that provides care for more than 17,400 Medicare patients, many of whom suffer from chronic health conditions that need to be managed to avoid frequent hospitalizations.

"Managing chronic health conditions can be exhausting! For example, people with diabetes have to think, what should I eat? What should I not eat? If I exercise, is my blood sugar going to be too low?" says Jane Abbey, care manager at CoxHealth. "Our job is to try and help patients not be so overwhelmed, to personalize their care plan so they don't have to change their whole existence due to their diagnosis."

To assist with personalized care coordination and management between visits, CoxHealth implemented Oracle Cerner's care management solution, HealtheCareSM. The organization built a centralized care management-focused team and this original team of six grew to nearly one hundred.

"In the early days, we participated in initiatives with the Centers for Medicare and Medicaid Services and the Bundled Payments for Care Improvement. Everything was manual and we spent a lot of time trying to identify the patients that we needed to work with and intervene on. Implementing HealtheCare has helped to reduce the manual workload, which has enabled our care team to focus on delivering patient care," says Tracy Mitchell, system administrative director of population health services at CoxHealth.

HealtheCare helps prioritize patients most in need of care management services through customizable candidate identification algorithms. It provides important context about a person’s care by bringing together data across the community into a single, living source of truth to enable better care coordination and monitoring.

"When we call our patients, leave them a message, or send them a letter, we use HealtheCare to document information," says Abbey. "We also document patient education and conversations. This helps provide a better picture of the patient's background to physicians and their care team."

CoxHealth also used Oracle Cerner’s HealtheAnalyticsSM: Cost and Utilization solution and Cerner Analytic Services to identify patients who would benefit the most from the care management program and further enhance how care teams interacted with patients they didn't see regularly in the clinic.

"We realized we had some inconsistent workflows happening, and that only a few of our nursing staff had care management experience. Using our dashboards, we were able to reassess and see where we were performing and where we were falling short. As a result, we standardized the onboarding process, developed a mentorship program, and used behavioral interviewing techniques to help the team learn how to quickly connect to patients on the phone. It tremendously improved our approach,” says Mitchell.

By developing these insightful action plans, CoxHealth achieved a 55.99% improvement in patients engaging in the complex care management program over a two-year period.2

"I believe when patients engage with our care team, we're able to demonstrate with statistical significance improvements in patient outcomes and total cost of care. We've seen a number of patients with diabetes reduce their A1Cs, and some of the improvement has been dramatic," says Mitchell.

In the future, CoxHealth is looking forward to continuing to refine their algorithms so the organization can better identify patients with an increasing risk for a hospital visit.

"I'd love to be able to really manage our patient populations so that we can keep people out of the hospital and help them manage their chronic health conditions, so they have a better quality of life. That's the goal," says Mitchell.

1U.S. Department of Health & Human Services

2Comparing the three-month average of 39.83% from December 2019 to February 2020 to the three-month average of 62.13% from November 2021 to January 2022 after implementing HealtheCare.

Client outcomes were achieved in respective settings and are not representative of benefits realized by all clients due to many variables, including solution scope, client capabilities and business and implementation models.