An Interview With Tami Snowden, MSN, RN, National Director for Ambulatory Care Management, Catholic Health Initiatives

As the United States moves into the next era of health care, the implementation of new models has resulted in new titles and job descriptions in hospitals and health care systems. Nursing Administration Quarterly's Editor-in-Chief Kathleen Sanford interviewed a nursing leader with one of these new roles. Tami Snowden is the system's national director for ambulatory care management. In this job, she works with physician and nurse leaders from across the continuum to plan and implement population health.

KS:Tami, you've been with your organization for less than a year. I know that your role is brand new to your system and probably new to most health care systems. Can you tell me a little bit about why Catholic Health Initiatives (CHI) feels it's important to develop population models on a national level?

TS:We understand that population health is needed if we are to coordinate care across all settings, for the betterment of whole populations, as well as for individual consumers. We want to transform our facilities that have previously been successful as primarily hospital businesses in our regions. Our model's premise is that it's incumbent upon providers to place the consumer at the center of all care. One way that we do that is by developing Clinically Integrated Networks (CINs) in all of our markets.

KS:Can you explain why CINs are important?

TS:Building a CIN is critical as a foundation for population health implementation. The development of CINs in local health care markets helps break down current health care silos of care. They were originally conceived as a way for hospitals and physicians to work together in business and care models for the benefit of consumers. From the consumers' point of view, more coordination between the outpatient and inpatient worlds will add to the quality of care and individual consumer experience. We've expanded our CINs to include other ambulatory providers, such as lab, durable medical equipment providers, specialty providers, acute care hospitals, post-acute care providers, pharmacies, home care, and, of course, primary care providers.CHI currently has 10 CINs across the nation, with one additional in the planning stages. Each CIN is a legal entity, utilizing shared governance between CIN providers and hospitals. As a team, they coordinate care and services across the continuum of care. Collaboration among providers offers increased primary care capacity and better communication through data sharing.

KS:You mentioned data sharing. How is that done in a CIN?

TS:In order to evaluate and help manage the health of a population, there must be an information technology infrastructure. We are building ours to ensure the security of consumer health information and to support all other clinical application within the organization. We've worked hard to improve user access and navigation within the health information exchange via portals. This will allow providers and clinicians to share information across settings and with consumers. Communication through data sharing includes a universal, shared electronic health record for each consumer in both the ambulatory and acute care settings.Within CHI, a clinical portal provides a single, complete view of clinical information from different OneCare applications (Cerner, Allscripts, NextGen, and Meditech). The portal provides real-time access to the consumer, as well as information clinicians' need. This makes it so that providers do not have to manage multiple systems and passwords. The timely exchange of data and access to information will soon provide easier retrieval of clinical data to improve the continuity of care. As a nurse, I'm particularly excited that we will be able to view an individual's medical history, regardless of which of our sites the individual accesses for care. The portal will aid us in making the right medical decisions based on a holistic view of the consumer.

KS:You mentioned OneCare. What's that?

TS:CHI's OneCare project included the implementation of an ambulatory electronic health record (AEHR) in more than 350 practice sites across 19 states. The AEHR will be utilized by more than 1500 providers and 3000 practice employees. It's a building block on the road to a shared consumer health record for all of our patients and will allow for secure electronic transfer of specific clinical information through the Health Information Exchange between the ambulatory and acute care settings, including pharmacies and laboratories.

KS:Information technology is one tool for population management. What are some of the others that your system is utilizing?

TS:Screening tools for high-risk populations are a necessity for the determination of high-risk consumers, as well as identification of gaps in care for a particular population, community, or individual. We use a readmission risk tool, risk stratification reports, predictive modeling, and a disease registry to identify individuals most in need of additional care.The Centers for Medicare & Medicaid Services (CMS) has recognized that 19% of consumers discharged from hospitals are readmitted within 30 days. In the acute care setting, we have implemented the LACE (Length of stay, Acuity of admission, Comorbidities and Emergency department visits) scorecard to evaluate a consumer's risk for readmission. The 4 data points employed in the LACE system are length of stay, acute (emergent) admission, comorbidity, and emergency room visits in the last 6 months. By creating a multidisciplinary intervention protocol for consumers with high LACE scores, we can implement early intervention practices, discharge readiness considerations, and postdischarge transition programming.1

KS:You mentioned the importance of risk stratification to population management. Could you say more about that?

TS:Risk stratification and predictive modeling reports pulled from claims data help identify the most appropriate consumers for whom an intervention is critical to the delivery of cost-effective care. Risk stratification tools assist the care team in closing the gaps via care based on evidence-based protocols. They allow us to be proactive in disease management and preventative care. Predictive modeling reports can also be utilized to assess the future health care needs of a population or community. When used for a specific individual, they allow us to initiate a personalized care plan for the consumer, which is not only more effective and efficient but also provides better customer satisfaction. Utilizing these reports within the ambulatory setting increased the community's quality of life through the avoidance of chronic disease, stabilization of chronic conditions, and mitigation of the opportunity for an individual to move into a higher-risk category.

KS:Why is a disease registry essential for population management?

TS:A disease registry is a system for the collection, storage, retrieval, analysis, and reporting of clinical information on individual consumers. It is used for assessing and improving health care outcomes for individual consumers, monitoring and improving the health status of consumer populations, assessing individual provider performance, benchmarking, and reporting. We use 2 data registry tools currently, McKesson Population Manager and Conifer Value-Based Care. Both tools are Web based and condition specific. They, and similar tools, help drive focused improvements and identify gaps in care, based on evidence-based protocols. Whatever tool an organization selects for its registry must meet the CMS Physician Quality Reporting System quality reporting needs.

KS:I know there are other disease registry and IT tools available for health care systems. What should nurse leaders look for in a system?

TS:Whatever tools a system selects, they must have the capability to integrate network data into a usable form by merging data analytics with clinical care and supporting quality improvement initiatives. There must be the ability to receive cogent reports based on the data. My system has the ability to extract data from all of our markets, hospitals, and physicians. That data is transformed through CHI's Enterprise Intelligence (EI) to provide holistic perspectives and to grant access to information valuable to our effectiveness and efficiency. The EI team is currently building our enterprise data warehouse, which will be the primary source of information, needed to support our strategic initiatives, such as evidence-based practice (EBP), core health care measures, and improved consumer satisfaction.

KS:I know that you are also involved in initiation of patient-centered medical homes (PCMH). Can you explain how these are important to CINs and population management?

TS:According to the Agency for Healthcare Research and Quality (AHRQ), the PCMH provides primary health care that is relationship based, with a focus on holistic care and partnering with consumers, family, and caregivers. AHRQ is also adamant that these medical homes address consumers' distinctive needs, culture, values, and preferences. The PCMH is responsible for coordinating care across the continuum for a broader system of care within a CIN.To assist our employed primary care practitioners as they prepare for even higher levels of quality, efficiency, and consumer satisfaction, we've embarked on a journey to transform their practices. Our major tenet is that consumers must be at the center of all activities. We are working to engage them as active participants in their own care, supported by a skilled care team.

KS:We hear a lot about care teams these days. Say more about what you mean when you talk about them.

TS:In order to create the most efficient and cost-effective care for a population, the PCMH must build a clinical care team consisting of a minimum of physicians and other providers, medical assistant, practiced registered nurse (RN), RN population health coach, and population health care coordinator. While previous clinic care structures often considered the physician the only individual involved in the consumer's care, clinics that are prepared for population health involve a team of diverse clinicians who work together to care for a defined population. All clinical team members are expected to work at the top of their individual licenses and scope of practice, while nonclinical team members perform administrative duties. Appropriate training and skills are essential for the provision of high-quality care. This clinical care team approach dictates that duties must be matched to the staff's skills and licenses. Various team members can provide care such as counseling, injections, and education. This frees up the physician to do what he or she is uniquely qualified to do: diagnose and treat illness.I thought that a quote from the Annals of Internal Medicine in September 2013 really sums up what we're going to need from these teams: "A culture of trust, shared goals, effective communication, and mutual respect for distinct skills, contributions and roles of each member."2^(pp620-626)

KS:Evidence-based practice has become very important in the acute care world. What is their purpose in the outpatient setting?

TS:The use of EBP integrated the most current clinical evidence and clinical expertise with the consumer, family, and community values and culture. Evidence-based practice helps facilitate health care decisions for providing safe, effective, person-centered care across the continuum. Effective utilization of EBPs ensures that consumers receive the right care, at the right place, and at the right time and ensure that professional staff provides the best and most current medical care according to up-to-date national evidence-based guidelines. These guidelines don't replace clinical judgment but are just as important in the outpatient world as they are in acute care.Successful implementation of EBPs requires standardized sets of evidence-based guidelines with a specific focus on optimal outcomes. Prevention, treatment, and utilization must be stressed, with an emphasis on a holistic approach to care. Again, even though the use of EBPs is essential, the clinical care team has an obligation to the consumer to provide shared decision making and mutually determined individual goals and allow for preferences and culture.

KS:When you listed who needs to be on the team, there were some new titles for care management. Could you fill in a little more detail about these roles?

TS:Part of the care team includes a care management group, who provide care management services. They engage consumers and their support systems for better care coordination and development of an appropriate care plan for the individual. Care managers also remove barriers to care for the high-risk population. In the past, care management services have been provided by payers. With the emergence of population health, care management services now have a place in the providers' office or at the CIN level.Centralized care management helps broaden medical home services across the entire network. A care management platform can leverage expertise from other care management staff. As health care systems work to reduce hospital admissions and readmissions, repurposing of existing acute care management staff can bring their talents to the ambulatory care management work within the PCMH. A centralized care management platform includes all levels of care across the continuum. Individuals who become part of this platform may currently have titles such as acute care manager, RN care transitions coach, RN population health coach, and population health care coordinator. By bringing these various professionals together, it is more likely that high-risk consumers with chronic conditions will be directed to the setting and level of care best suited for their individual needs. Centralized care management platforms will eliminate gaps in care during a transition to any level of care because it includes a care plan that follows the consumer throughout the continuum.

KS:Have you been able to successfully establish a centralized care management platform for your large system?

TS:CHI is in the early stages of implementing a centralized care management platform that can be housed within the CIN. The consumer will have the benefit of a team of care management experts who align their efforts by sharing information to enable seamless and effective care coordination across settings and through transitions. Our platform will also provide a central phone number for consumer access to guidance, support, and answers to questions, which we believe will lead to a positive consumer experience.

KS:You mentioned that Care Transitions is an important part of population management. Please say more about how that works.

TS:A Care Transitions program is an essential element to implementing population health because it is an approach to addressing preventable admissions. Recently, with the CMS focusing on readmissions and imposing penalties to hospitals with high readmission rates, more health care systems are moving to a Transitions of Care Program. As I said before, CHI has implemented the LACE screening tool to identify consumers at risk for readmissions on the day they are admitted to the hospital. Discharge planning starts immediately, led by the RN Care Transitions coach. The model we use is the one first initiated at Boston University in 2009.3 Known as Project RED, or Re-Engineered Discharge, this model includes reviewing the written discharge plan, assessing and educating the patient concerning his or her diagnosis, assessing the patient's understanding, communication with the primary care provider, and coordinating care and transition with the ambulatory care management staff.There are studies that evaluate these interventions and their efficacy in decreasing emergency room utilization and rehospitalization rates, while encouraging consumers and families to take an active role in their health care. One study in 2004 found that "older adults moving between different health care settings are particularly vulnerable to receiving fragmented care."4^{(pp1817-1825)} That same research showed that by taking the actions I've described rehospitalization and emergency rooms visits are decreased at 30, 60, and 90 days postdischarge. Another study that incorporated interventions with a nurse discharge advocate to assist with follow-up visits, medication reconciliation, consumer education, and a booklet of information demonstrated reduced hospital utilization within 30 days of discharge.4

KS:Much of what you are talking about included engaging patients, or in the continuum language, consumers. Can you give examples of how consumer engagement can be increased?

TS:There is growing evidence that incorporating educational and supportive interventions in collaboration with the consumers helps modify unsafe health practices and promotes accountability for their own health.5 Engaged consumers are better self-managers. They utilize self-management techniques to effectively manage their chronic conditions while taking an active role in their health care.6Engagement work must include a diverse set of modalities and must be customized to meet the specific needs of individuals. It can include health coaching, the use of clinical consumer portals for communication between the clinician and the consumer, and motivational interviewing. Motivational interviewing allows for a 2-way conversation so that providers can learn what is important to the consumer. The care plan can then be tailored to meet the consumer's goals, because just telling the consumer what he or she "needs to do" seldom works. The collaborative approach between the consumer and the clinical care team results in identification of challenges and barriers for the consumer and helps set health care priorities and goals for the individual and results in mutually agreed-upon treatment plans.

KS:It seems to me that we sometimes think our health care systems must do everything for populations. Are there other resources that we should be coordinating with to provide the best care for our communities?

TS:Local and state recourses are part of the community and the population they serve, just as much as the health system is. Social service agencies, public health agencies, schools, and churches have always looked at health from a population standpoint. Community resources and support often overlap and are less formal and structured than our health care systems. Development of partnerships, shared knowledge, and connections with these resources are crucial for a health system with the goal of benefiting the health and well-being of consumers. These partnerships can enhance community health because they offer supportive programs that focus on the culture of the community. By combining resources, gaps in care can be addressed while integrating the consumer's values.

KS:It's obvious that you have a passion for wellness. Do you have any final words about the next era of health care and what nursing leaders should be thinking about as we move into population management?

TS:As nursing leaders we know that a competitive edge, growth, and success are the aspiration of all businesses, including those of us in the health care business. Moving into the next era, we as nurse leaders find out passion in doing what is right for the health of individuals and communities. Both business needs and health needs will be met in the future if we understand that a change in culture is needed to successfully implement population health.A sound foundation for caring for chronic illness within a community is essential. A team approach with a diverse group of providers focusing on the consumer will break down current care silos so that we can provide holistic value-based care. Cultural change is difficult and challenging, but by using the key building blocks I've mentioned in this interview, any system has the ability to transform its current pay-for-service structure to a value-based population health structure. We are on a journey to transform health care. Its evolution is something nurse leaders can embrace.

-Kathleen D. Sanford, DBA, RN, CENP, FACHE

Editor-in-Chief

Nursing Administration Quarterly

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