How AdventHealth's tailored patient outreach closed care gaps

AdventHealth saw growing care gap issues

As a clinically integrated network, AdventHealth has deep insights into patient health metrics.

"For any member or patient who is in any form of risk-based contract related to AdventHealth's clinically integrated network, we're able to track those claims and follow HEDIS guidelines, which are what we use to set our quality," Calhoun said in an interview.

But like most healthcare organizations nationwide, those metrics left much to be desired. Patients weren't up to date on key preventive measures -- particularly the ones spelled out in HEDIS -- and AdventHealth was struggling to engage those patients with their usual strategies.

"When we first started this journey of trying to connect more closely with our members, we noticed that traditional outreach just wasn't working. We just weren't able to connect the same way," Calhoun recalled.

Typically, AdventHealth's population health side of the business would do single-message campaigns based on claims data and whether the patient had fallen out of HEDIS metrics. The campaigns were email-only and involved a single message trying to speak to all patients on the campaign.

"We were missing a whole bunch of different segments of members because the language, imagery and design of the campaign were not built for multiple messages or touch points," Calhoun noted.

Through partnership with some of its contracted payers and a health IT vendor, Upfront by Health Catalyst, Calhoun and her team of population health experts were able to design a multi-channel patient engagement strategy.

Segmenting out more targeted patient outreach

Central to Calhoun's approach was partnership.

In addition to collaboration with AdventHealth's vendor, Calhoun said communication with payers to learn more about their member engagement strategies was instrumental.

"We had one payer contract in particular that was showing some success using personalized outreach and tailoring their messages to reach cohorts," Calhoun recalled. "They were dividing their messaging based on gender, age and language."

AdventHealth wanted go deeper than that payer had, but still, their success was encouraging.

Calhoun and her team assessed the patient data they had on hand and tailored patient outreach based on the barriers the care patients faced. In some cases, barriers involved patient navigation and education, while in others it involved more intuitive patient scheduling. Some campaigns addressed social determinants of health.

While AdventHealth's population health group now focuses on numerous types of campaigns -- one recent campaign focused on redirecting patients away from the emergency department where appropriate -- Calhoun said it was important for the organization to start with primary care access.

"We thought to benefit the members best would be to get them in with their primary care provider, to make sure that they're seeing them annually again," Calhoun explained. "And if they hadn't had a face-to-face visit in the last 12 months, that would be the most important because that kicks off the follow-up of additional health metrics and preventive services throughout the year."

That's cascaded into a broader, multi-channel patient outreach effort that, according to Calhoun, has ultimately closed care gaps. Within 90 days of outreach, AdventHealth saw 41% of patients close their physical exam care gap. In the same timeframe, the organization saw 36% of patients close their diabetes care gap and another 23% close their mammogram care gap.

Not only that, but the patient outreach effort helps AdventHealth stand out among providers looking to contract with clinically integrated networks.

"This has really become something that we can talk about with providers -- new ones who are going to join our network. We can tell them this is an added service that we offer," Calhoun said.

Provider engagement aside, it's the closing of care gaps that's essential to AdventHealth's overall mission, Calhoun suggested. Preventive care access helps stave off more disruptive and costly care episodes down the line.

"Our focus was to try to catch these patients and evolve and engage them before they need any healthcare," she concluded. "That's the whole point of preventive care. It's in between visits with your provider that we want to make sure we're reaching out and we're there for them and that they're feeling whole. That's our promise."

Sara Heath has reported news related to patient engagement and health equity since 2015.