Predictive analytics is helping ACOs like Buena Vida y Salud advance value-based care. Through a partnership with HDAI, they use data to stratify patient risks and streamline care management, focusing on high-priority areas like pneumonia prevention. Digital twins aid in tailoring analyses to individual patient populations, fostering trust with providers. Early successes include stable admission rates, and plans involve improving care for patients with chronic kidney disease. Leveraging advanced analytics, ACOs anticipate transformative enhancements in value-based care delivery.
Accountable Care Organizations (ACOs) play a pivotal role in the healthcare landscape’s shift towards value-based care. However, achieving success in population health management and care coordination demands investments in innovative technologies. Predictive analytics stands out as one such technology, enabling providers to effectively harness patient data for risk assessment.
In a recent episode of Xtelligent Healthcare Media’s Healthcare Strategies podcast, Dr. Sheila Magoon, the Executive Director of Buena Vida y Salud ACO and the South Texas Physician Alliance, along with David Clain, the Chief Product Officer at the Health Data Analytics Institute (HDAI), shared insights into their predictive analytics partnership and its role in advancing the ACO’s value-based care initiatives.
Leveraging Predictive Analytics to Foster Home-Based Patient Wellness
When Buena Vida y Salud and HDAI initiated their partnership in April, Dr. Magoon anticipated a fresh perspective on their patient population and a step closer to the goal of “keeping patients healthy at home.”
Upon delving into HDAI’s predictive analytics platform, Dr. Magoon and her team were presented with multiple options for data analysis, encompassing assessing risks like unplanned admissions, pneumonia development, and worsening heart failure.
HDAI assisted Buena Vida y Salud in generating reports for these specific patient populations. Consequently, the ACO created cohorts, categorizing patients into advanced care, chronic care, and rising risk groups. Providers were then equipped with these lists, serving as guides for their care management strategies.
Nevertheless, this approach initially posed a challenge for Dr. Magoon. One provider expressed feeling overwhelmed by the wealth of information. To address this, they streamlined their focus to high-risk patients requiring unplanned admission prevention, a strategy that aligned with the provider’s existing workflow.
Buena Vida y Salud extended this flexible approach to other providers, enabling them to select patient cohorts or use cases that HDAI’s platform could enhance, thus actively engaging providers rather than solely relying on internal care coordinators.
Dr. Magoon emphasized the importance of this approach in guiding providers who may be eager but unsure about where to begin.
Addressing Pneumonia Prevention and Hospital Admissions
Buena Vida y Salud’s ongoing campaign is centered on vaccinating high-risk patients against pneumonia, particularly as flu season approaches. Pneumonia ranks among the top ten drivers of hospital admissions for the ACO, making its prevention a paramount objective. The ACO utilizes HDAI’s platform to encourage high-risk patients to receive pneumococcal vaccines, recognizing that while it may not eliminate pneumonia-related hospitalizations, it represents a significant step toward achieving its overarching goal of keeping patients healthy at home.
Data Quality and the Role of Digital Twins
To empower ACOs in reaching their value-based care objectives, HDAI employs a combination of predictive modeling and digital twins. Digital twins involve creating virtual representations of individuals, objects, processes, or systems to simulate potential outcomes.
David Clain of HDAI explained that digital twinning allows for tailored analyses, aiding in discussions with individual physicians about specific patients needing support or intervention. This approach caters to the unique patient populations that providers serve, addressing their concerns regarding tool applicability.
Building trust with providers is essential, especially if predictive analytics vendors can substantiate their claims with data. Clain highlighted the importance of demonstrating how a provider’s patient population compares to others and identifying areas for improvement.
Moving Beyond Traditional Data Sources
Historically, ACOs have relied on Medicare data and risk adjustment factor (RAF) scores for insights into patient populations. However, these sources have limitations in capturing the complexities associated with individual patient health.
Digital twins, as Clain suggested, represent a “third wave” of analysis. They connect de-identified data from diverse sources to ACO populations, allowing benchmarking against precisely-matched comparison groups. This approach enables ACOs to measure outcomes across various metrics, providing a baseline for discussions with providers.
Early Successes and Future Endeavors
While Buena Vida y Salud’s partnership with HDAI is still in its infancy, it has already yielded some promising outcomes. Currently, the ACO’s admission rates remain stable, which is particularly notable given the increased hospital admissions and emergency room utilization following the end of the public health emergency.
However, Dr. Magoon acknowledged that it may take a year of collaboration with HDAI to fully assess the partnership’s impact and observe patient outcome trends. Looking ahead, the ACO’s next project focuses on improving care for patients with stage 3 chronic kidney disease (CKD3). By leveraging advanced analytics, Buena Vida y Salud aims to break down this cohort into manageable segments and make a substantial impact on their care.
Excitement abounds among Dr. Magoon and her colleagues, as they see numerous opportunities to enhance value-based care delivery through advanced analytics. They eagerly anticipate the journey ahead and the potential improvements it can bring to Buena Vida y Salud’s patient care initiatives.
