Skip to main content
Skip to footer

Community Care Programs Leading the Way for Population Health

Published on 1/22/2018

Located in Winona, Minnesota, Winona Health is an independent, nonprofit community-owned health care system. In 2013, Winona Health launched the Community Care Network (CCN), a psychosocial preventative model that seeks to empower clients to better self-manage their health and well-being. Rachelle Schultz has been the president and CEO of Winona Health since 2002.

It is no secret that health care costs continue to rise. Most health systems in the United States are under increasing pressure from payers and policymakers to keep patients healthy and out of the hospital — a pressure that, for many, is at odds with the traditional hospital care and business models.

These pressures have been building for years. Health care reform, alternative reimbursement models and regulatory changes have dominated the conversations with health care leadership. As time passed, it became clearer and clearer to us: We have hit the mature phase of our industry and we need to reinvent health care. The era of price increases as a method of managing the increasing cost of providing health care was ending, particularly as it landed on our local employers.

Most of us have long recognized that something needs to be different, and we have all talked about what the new model of health care should look like. Prior to the passage of the Affordable Care Act, I had the opportunity to participate in a quality forum sponsored by the Robert Wood Johnson Foundation, which is where I first heard the term “accountable care organization.” This concept peaked my interest.

I thought about accountable care in the context of Winona Health and what we were experiencing with our patients. We were experiencing frequent emergency department (ED) visits from patients with preventable or treatable illnesses, an escalation of patients with chronic diseases who were not managing their care independently, and we had “frequent flyers” to our inpatient units. (The fact that our industry uses the term “frequent flyer” in relation to patients should throw up a red flag when it comes to patient-centered care.) We wanted to change the way we were caring for these community members.

Over time, these pieces coalesced into a new vision of health care for many of our patients — our Community Care Network (CCN). Our program includes a multidisciplinary team of health care providers and clinical staff, including social workers, dieticians, physical therapists and student health coaches. The CCN focuses on engaging with individuals who have histories of high ED and inpatient utilization or are at risk of becoming high utilizers.

In this work, we found that underlying psychosocial needs were a dominant root cause prohibiting patients from achieving optimal health outcomes. Today, social determinants of health is widely discussed in the industry, and I have had plenty of opportunity to observe their impact in our patients’ lives. I often say that what is broken and fragmented in my community shows up on the doorstep of our ED.

Sometimes I am asked what led Winona Health to this community-driven approach to health care. In fact, there is no single reason. This was about opening the door to a new vision. We created the CCN because we believed we could make a difference. We believed we could keep people out of the hospital and the ED and could partner with them in different ways. It was about recognizing that the old model was disintegrating and asking ourselves: What experiments can we run, what should we pilot?

And what did we find? It works! In big ways.

Community health care programs: opportunities for change

Community care programs can be risky. Many health care systems face workforce issues, provider recruitment issues, reimbursement challenges across every payer type, regulatory challenges, new and expensive technologies or drug cost pressures — often all at once. All these factors are harbingers that our industry needs to transform — and we can lead the way or we can be dragged along, but via the aforementioned factors and many others, change is well underway.

In times of transition we look for safety nets, but these can impede our efforts at innovation. The argument for waiting to launch an experimental project — and the CCN started out as very much an experiment — until we are sure we will be reimbursed for it does not make sense to me. We started the CCN without the expectation that we were going to get paid for it, because too often, starting with that expectation is a barrier to change. We wanted to test and see if we could make a case for payment for the new delivery model based on our outcomes.

We have had to retool many clinical and support processes to make the CCN successful. While we did not lead this work focused only on finances, our desired outcome for this program is financial sustainability.

I am not dismissing the need to be financially successful, but financial results are outcome measures. Financial sustainability comes after we define and design what we want to deliver. The CCN started primarily from listening to the consumer perspective — to our patients. What are their needs? If we are not listening to the patients, I am not sure why we are providing care in the first place.

Understanding the patient perspective

When we evaluated why some people had recurring visits to the ED or were admitted to the hospital multiple times in a year, we realized it was not because of anything we were doing — we are really good at taking care of people, resolving acute issues and discharging them. It was more about what we were not doing.

A 20- or 30-minute clinic visit, or an ED visit, or a few days in the hospital, gives clinicians only a snapshot of a person’s life. A person’s health and well-being must be considered in the context of their life circumstances. To understand our patients’ needs, we must look at what is going on in their lives. Can they afford their medications? Are they taking their medications as prescribed? Is health literacy an issue? Do these individuals need help to understand what is going on with their chronic condition once they are out of the hospital? Add to all of that, do they have stable housing, social supports and food sufficiency? As health care professionals, it is important for us to understand our patients holistically — because when things fall apart, they are going to come back to us.

To that end, we made it a priority to be a catalyst and engage our community social service agencies. The CCN is an integrated social-medical program: CCN health coaches, all of whom are college students in a variety of disciplines from Winona State University, work with assigned clients, typically visiting individuals in their homes or wherever they feel most comfortable. Their goal is to be a liaison between the clinical team and the client. Through patient education and resource development, they support clients as they learn to manage their chronic health conditions. Health coaches are also the eyes and ears of the team, helping to bridge understanding for all parties of the life context for each client.

In this way, the CCN acts as a catalyst, pulling community organizations together to coordinate among all our respective programs and services. Because at the end of the day, it is not just the hospital or the social organization charged with keeping our community healthy: We are all responsible for our population’s health and well-being. If we broaden our scope and think differently about those types of resources, we can foster a more holistic approach to both health and care across our community.

The community care program experiment: execution and results

The CCN started with one nurse and one social worker, and has since grown as we have engaged in shared savings arrangements for the Medicaid and Medicare populations. Our evolution came from interviewing patients about their needs, understanding root causes for high ED or inpatient utilization, identifying patient barriers to good health and well-being, engaging with them personally and continuously improving our processes. Driving us was our desire to make a difference and impact the total cost of care.

Our initial data saw significant reductions in ED utilization and improvement in chronic condition management. On average, clients had 0.9 fewer ED visits following program enrollment (4.7 visits pre-enrollment versus 3.9 visits post-enrollment). There was also a decrease, on average, from 1.95 inpatient stays pre-enrollment versus 1.61 inpatient stays post-enrollment. While this was a relatively small population initially (n=59), we have sustained these reductions with subsequent patients added to the CCN. Since 2013, we have enrolled more than 350 clients in CCN.

These reductions in ED and hospital utilization have translated into economic savings: Mean total billed annual charges per CCN client decreased, on average, $18,907 when comparing the years before and after CCN enrollment. This translated into more than $1.1 million in total cost of care savings over a three-year period. This is revenue we did not receive, as the savings went to the respective payors (primarily Medicare and Medicaid). However, this is exactly what has benefited us in our shared savings arrangements.

But there is still so much work to be done. We are constantly evolving the program to understand the right balance between clinical staff, social services staff, health coaches and so forth. We are continually looking to improve outcomes with patients.

For hospital leaders interested in community programs, there must be a commitment to it — and an understanding that it is going to take a little bit of time to see results. We started small, and we did not put our organization at risk in terms of reimbursement. Ultimately, the CCN positioned us to demonstrate an effective approach to delivering high-quality care with high patient satisfaction at a lower cost. Most importantly, as we have done this work, we have gotten a lot closer to the consumer. We are learning how to walk in our patients’ shoes, and that is clearly redefining how we deliver care.

Cerner is focused on connecting traditional venues, the health continuum and advanced information about a person’s lifestyle to empower individuals in their health and care. Learn more about our population health management solutions here.

Want more information about Winona Health's Community Care Network? In this podcast from Rachelle Schultz and Cerner ITWorks Senior Vice President Dick Flanigan, you’ll learn more about innovative approaches to rural patient care.