SPH Population Care
™
Summary:
The transition to value-based care has proven immensely challenging, especially in places like
the Southeast United States, which is consistently ranked as one of the least healthy regions.
In this corner of the country, which stretches from Kentucky to the Gulf Coast of Louisiana,
down to the Florida Keys, Americans are significantly more likely to die of
cardiovascular disease than their Northern and Western counterparts
1
.
Unsurprisingly, many physician groups and healthcare organizations
have sought to improve the health of individuals in these states, but
progress is sometimes slow given the immense number of demographic,
socio-economic, and cultural influences that affect this region.
The Consortium for Hypertension Control (COSEHC), a professional healthcare organization
headquartered at the Wake Forest School of Medicine in North Carolina, structures professional
education, conducts research, and provides quality improvement consultation with a mission to improve
cardiovascular health. COSEHC provides its services to large and small healthcare organizations, individual
practices and payers.
In 2015, COSEHC was one of 29 healthcare organizations that was awarded a cooperative agreement under
HHS' Transforming Clinical Practice Initiative (TCPI)
2
. The groundbreaking initiative, designed to help
clinicians achieve large-scale health transformation, is part of a larger strategy advanced by the Affordable
Care Act to strengthen the quality of patient care, while spending healthcare dollars more wisely. Awarded
organizations called Practice Transformation Networks (PTNs) work with enrolled practices providing
technical assistance and resources to engage clinicians, improve health outcomes, reduce unnecessary
utilization and healthcare costs, and to successfully prepare for value-based care delivery.
After 3 years into the 4-year TCPI, the COSEHC PTN called QualityImpact, achieved improved baseline clinical
and utilization outcomes. The organization exceeded its goals through the utilization of established, evidence-
based guidelines, practice re-design strategies and a technology partnership with SPH Analytics, which
offered access to its data aggregation and a population health platform. The technology allows direct insight
into performance metrics and pinpoints high risk patients and care gaps which enables the integration of
data-driven quality improvement strategies into a practice's workflow.
1 https://www.americashealthrankings.org/learn/reports/2017-annual-report
2 https://innovation.cms.gov/initiatives/Transforming-Clinical-Practices/
Leveraging Data to Drive Clinical Transformation
in a High-Need Patient Population
Case Study
