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Delta Health Alliance
SUCCESS
STORY
STONEVILLE, MISSISSIPPI, U.S.A.
Managing diabetes care for better clinical and financial
outcomes
Delta Health Alliance (Stoneville, Mississippi) is an organization that offers a suite
of Allscripts solutions that drive better patient care and focus on improving patient
engagement in the community. With a federal Beacon Community grant from the
U.S. Office of the National Coordinator for Health Information Technology (ONC), the
organization demonstrated new and innovative ways to improve care for people with
diabetes, while at the same time lowering the cost of care.
CLIENT PROFILE:
• Community-based, nonprofit
collaboration of 60 FQHC, rural
health, and private practice
physicians
• Goal is to increase access and
availability of health care for
400,000 people living in the
Mississippi Delta region
• Purchased a three-provider rural
Experience
A lack of physicians in the Mississippi River Delta region can limit patients’ access to
health care. Providers need solutions that can help identify and improve communication
with at-risk patients. To help meet demand for proven technology, the Delta Health
Alliance is a collaboration of 60 Federally Qualified Health Center (FQHC), rural health,
and private-practice physicians focused on researching the best methods.
With a three-year federal Beacon Community grant from the ONC, Delta Health Alliance
implemented several programs in 19 rural counties to improve care for diabetic patients.
The occurrence of diabetes is growing at an alarming rate and is even more common in
the Mississippi Delta than national averages.
“We have doctors who are very passionate about treating diabetes in the Delta,”
Assistant Vice President of Information Technology and Chief Information Officer Daniel
Thomas said. “Through the Beacon Community grant and using Allscripts solutions,
doctors are able to give the same level and quality of care to these patients that they
would receive in major metropolitan areas.”
Working through the Mississippi Health Information Network (MSHIN), the state’s health
information exchange (HIE), Delta Health Alliance implemented various programs
throughout four hospitals and 37 clinical practices throughout the Delta.
Solution
Delta Health Alliance manages technology applications for its member physicians, and
it provides continuing education to help improve health care. All physicians currently
use TouchWorks electronic health record, Allscripts Revenue Suite and FollowMyHealth
patient engagement portal.
www.allscripts.com
health clinic in 2013
• Collaborates with healthcare,
governmental, academic and faithbased organizations
SOLUTIONS:
• Allscripts TouchWorks® EHR
• Allscripts Revenue Suite™
ºº Allscripts Practice Management™
ºº Allscripts Payerpath™
ºº Allscripts Practice Performance™
• Allscripts Care Director™
• Allscripts FollowMyHealth®
OUTCOMES:
With a federal Beacon Community
grant to improve care for diabetic
patients:
• Enhanced clinical decision support,
known as “Care Guides” used
during 31,000 exams in 29 targeted
clinics, substantially reduced blood
sugar levels, obesity and blood
pressure
• Improved care transitions in three
Delta hospitals held readmission
rates to 3.1%, compared to the U.S.
national average of 26.3%
• Better medication management
in nine locations helped three
out of four patients reduce blood
sugar levels, saving an estimated
$300,000 in hospital admissions and
chronic care costs
Achieved Patient-Centered Medical
Home, level 2 status
All 60 providers have attested to
Meaningful Use Stage 1 and Stage 2,
earning $2 million in incentive funding
MEETING REPORTING REQUIREMENTS FOR INCENTIVE FUNDING
“TouchWorks EHR is highly customizable, yet it’s completely code-based in the
background…the reporting is very robust,” Thomas said. “TouchWorks allows providers
to document the way they want to document, it gives them the flexibility to do what they
want to do in their practice…and still meet all regulatory requirements.”
Thomas reports that all Delta Health Alliance providers have successfully attested for
Meaningful Use, both Stage 1 and Stage 2. Participation has earned affiliated practices
$2 million in incentive funding. Leland Medical Clinic, supported by Delta Health
Alliance, also achieved Patient-Centered Medical Home (PCMH) status, certified level
2 in 2015. “It’s a big deal…we’re the only one in the Delta and one of very few in the
state.”
Delta Health Alliance also participates in the Mississippi Medicaid Health Demonstration
Project with help from Care Director. TouchWorks reporting will enable the organization
to show a decrease in the conversion from pre-diabetes and diabetes once it starts
interventions. “We can use Care Director to implement care interventions, and track
them to show they are lowering disease states,” Thomas said. “We hired a population
health manager, a nurse, and she thinks it’s the greatest thing since sliced bread.”
Outcomes
CARE GUIDES ENABLE ENHANCED DISEASE MONITORING
Delta Health Alliance incorporated best practices and national care standards into
TouchWorks EHR and developed Care Guides. These tools help clinicians by alerting
them to evidence-based tests, medications, education and other requirements for
specific patients and diagnoses.
The Beacon Community Grant provided funding to implement the diabetes Care
Guide with specific reminders for the types of tests that diabetic patients require
more frequently, including glucose screenings, hemoglobin A1c (HbA1c) tests, foot
examinations and eye screenings. Implementing these Care Guides in 29 targeted Delta
clinics, clinicians used them during 31,000 examinations.
“Using TouchWorks and the Care Guides through our Beacon Community grant, we were
able to show a statistically significant decrease in HbA1c values for our participating
patients,” Thomas said. “We lowered obesity and [Body Mass Index], and we actually
showed the ability to control blood pressure. It’s all documented in the [TouchWorks]
EHR.”
REDUCING HOSPITAL READMISSIONS WITH BETTER CARE TRANSITIONS
Working in three participating hospitals, the program provided trained “health coaches”
to assist medical teams during discharge. Health coaches then follow up with patients by
phone to answer questions about medication, routine self-management tests, coordinate
transportation and direct patients to primary care to address problems.
Physicians referred 1,446 patients to the program over three years, and only 14 (3.1%)
were readmitted to a hospital, compared to a national average of 26.3% readmissions
among diabetic patients. With each inpatient day for preventable, unscheduled
readmission costing an average of $2,679, this program demonstrates significant cost
savings.
MEDICATION THERAPY MANAGEMENT SERVICES IMPROVES COMPLIANCE,
SAVES MONEY
Most diabetic patients take a variety of prescription drugs to manage blood glucose
levels, control blood pressure and reduce cholesterol levels. Patients may require other
medications to address a variety of complications, and those needs can change over
time.
To help patients successfully manage complex medication regimens, Delta Health
Alliance integrated healthcare IT with patient education and patient care. Pharmacists
on site at local clinics assist patients with comprehensive medication reviews and
recommends adjustments, if needed. Because the pharmacist was able to view and
document information in TouchWorks EHR, it helped improve communication among the
care team.
Leigh Ann Ross, Pharm.D., associate dean for clinical affairs at the University of
Mississippi School of Pharmacy, said, “To hear some of the inspirational stories of Delta
residents and how their diabetes had never been controlled, and to see how excited they
were about managing their disease through weight loss and healthy eating and proper
medication, really spoke to me.”
WHAT’S NEXT FOR DELTA HEALTH ALLIANCE
After the Beacon Community grant ended, providers realized they could apply the same
management strategies, such as the Care Guides, with other chronic diseases. Delta
Health Alliance anticipates continuing its close partnership with Allscripts to manage for
better clinical and financial outcomes.
“My working relationship with Allscripts is one of the best client-vendor relationships I’ve
ever had,” Thomas said. “They understand what we need and make things happen and
make things work….to help us deliver good patient care in the Delta.”
The Delta Health Alliance gratefully acknowledges support of this project through the Office of National
Coordinator Grant Number 90BC0004-01.
Delta Health Alliance
Copyright ©2016 Allscripts Solutions, LLC and/or its affiliates. All rights reserved.
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SUCCESS
STORY