American

College of Healthcare Executives SETC

2015 Student Scholarship Case Study

Claudia Neumann
University of Houston Clear-Lake, UHCL


Introduction ................................................................................................................................................................. 1
1. General Considerations ................................................................................................................................... 1
Relevant Characteristics of ABC System ..................................................................................................... 1
Development Goals for ABC System ............................................................................................................. 1
2. Population Health .............................................................................................................................................. 1
Developing the Population Health Focus at ABC System .................................................................... 2
3. Engaging Partners ............................................................................................................................................. 2
Nurse Health Line ................................................................................................................................................. 2
Population Health Improvement ................................................................................................................... 2
Promoting ABC-PHIP Partner Programs .................................................................................................... 3
Organizational Change ....................................................................................................................................... 3
PHIP-CHANGE Motivating a culture focusing on population health ..................................... 4
4. The Role of Quality in ABCs new Strategic Focus ............................................................................... 4
5. Economic Effects ................................................................................................................................................ 4
6. Conclusion ............................................................................................................................................................ 5
Appendix ........................................................................................................................................................................ 6
Illustrations ............................................................................................................................................................. 6
References ............................................................................................................................................................... 6

ACHE-SETC Student Scholarship 2015 Case Study Claudia Neumann |

Introduction
The non-profit multi-hospital system ABC System, located in Houston, TX, initiated a culture shift
to focus on population health, and the impact on the community it serves. Demand for its services
outweighs the supply, particularly in the emergency room. This case study introduces the concept
of population health, illustrates ABC Systems strategy to engage partners, ensure quality, and pro-
mote its program. It also briefly projects expected effects on the systems operating margin.

1. General Considerations
Relevant Characteristics of ABC System
As a multi-hospital system, ABC is perfectly positioned along the continuum of healthcare, where
a system can guide and track patients over time through a comprehensive array of health services
spanning all levels and intensity of care. [1] Its excellent location factor in Houston, close to the
Texas Medical Center (TMC), the largest medical center in the world, facilitates manifold opportuni-
ties to partner with other institutions in the TMC. As a non-profit system, ABC has fewer ways for
raising capital than for-profit organizations, which can be offset by alliance with strong partners.

Development Goals for ABC System

My goals as the CEO, in order to move ABC forward in a dynamic healthcare environment, are:
1. Optimize patient flow and resource utilization, especially in the ER;
2. Plan and successfully implement a comprehensive population health program.

2. Population Health
Population health expert David Kinding defines population health [2, 3] as health outcomes of a
group of individuals, including the distribution of such outcomes within the group, and illustrates
the mutually influencing factors (a) Health outcomes and distribution in a population, and (b)
Patterns of health determinants over a life course. Factor (c) Policies and interventions at the

ACHE-SETC Student Scholarship 2015 Case Study Claudia Neumann |

individual and social levels, [2] affects both of them (see appendix, Figure 1). Experts agree, that
distribution and delivery of population health reach far beyond public health institutions, and in-
clude a range of clinical and non-clinical stakeholders. [4]

Developing the Population Health Focus at ABC System

In this context of population health, as the CEO of ABC Systems, I consider the following steps:
Use existing services like community services, etc. to achieve short term and lasting changes of
individual behavior (see determining factors [3]) to influence outcomes
Use social/physical environment to inform, educate, and achieve large-scale behavioral change.
Use health care institutions to facilitate and promote programs, and function as quality gates.

3. Engaging Partners
Many supportive services already exist; yet institutions rarely integrate them, and the population
does not know and/or efficiently use them. My strategy to impact population health is to analyze
disease prevention/-control programs in the Houston area, and select those, which excel and fit
best, for a partnership program. A premium alliance with Memorial Hermanns Nurse Health Line
[5] will tackle our demand-supply imbalance and generate triple-win for partners and patients.

Nurse Health Line

Already in 2004, a study about a Nurse Advice Line showed that Most patient actions (68%) dif-
fered from their original healthcare plan, with [] (46%) choosing a lower intensity of care. [6]
ABCs partnership with Memorial Hermanns Nurse Health Line, will benefit the helpline (expand
their use and increase their popularity), and help ABC System to optimize resource utilization, by
redirecting about 50% of the patient-flow to more appropriate facilities (chapter 1 goal 1).

Population Health Improvement

Many population health programs already exist, and largely the problem is only lack of information
and accessibility, e.g. regarding prevention/control programs for Diabetes, Coronary Heart Disease,
2

ACHE-SETC Student Scholarship 2015 Case Study Claudia Neumann |

and especially obesity as an important general health risk. Another key concern is Alzheimers and
further cognitive or dementia impairments. ABC System therefore initiates the ABC Population
Health Improvement Program (ABC-PHIP), to identify and promote excelling services for those
conditions, and include them in ABC Systems patient care path (chapter 1 goal 2).

Promoting ABC-PHIP Partner Programs

A multi-faceted communication campaign will introduce MHs Nurse Health Line, and the ABC-
PHIP to Houstons patients. Since target groups are diverse and of all ages, we will implement in-
formation campaigns via local radio/TV, together with strong social media marketing across plat-
forms (Facebook, Twitter, Google+, etc.). Editorial contributions and education videos, will explain
the programs in local media. In a second wave, text message promotion will reach those parts of the
population, who use their mobile phones as primary communication medium, and are not other-
wise tech-savvy or for other reasons not engaged in social media.
To reach out to the elderly, there is a need for individual promotion. Their habits show that indivi-
duals from within their social environment are trusted most, so special education programs will
train fit seniors to share information about ABC-PHIP, comparable to word-of-mouth advertising.
Our second strategy involves local stores, like e.g. the grocery stores they frequently visit. Kroger is
a prominent example for this strategy (community-based Diabetes Control Program at designated
Kroger stores in selected cities including Houston already in 2011 [7]). A study will conduct
research regarding the elderly populations everyday habits, and conclude which approach would
best serve them.
All promotion activities will use both ABCs network and all partners communication channels.
Where ABC itself misses resources for campaigns, agreements with its partners will grant funding.

Organizational Change
Increasing collaboration and networking with partners inside and outside the world of healthcare
institutions requires a notable paradigm shift and organizational change. It is important to align all
3

ACHE-SETC Student Scholarship 2015 Case Study Claudia Neumann |

employees of ABC Systems with the new strategy and gain their full support. Potential implications
for employees have to be detected and addressed early, and all staff has to be turned from affected
into participating and supporting forces. An internal PHIP-CHANGE program will run these tasks.
PHIP-CHANGE Motivating a culture focusing on population health
The starting point to manage this paradigm shift is an open culture, understanding the importance
of prevention, and more independent health management of patients. Being able to let go of tasks
that previously belonged to the domain of our institution, without fear to lose ground in the market,
as well as especially for medical staff not being scared of well-educated patients, are very im-
portant goals of PHIP-CHANGE. With employee coaching, get-togethers, and management by walk-
ing around (MBWA), PHIP-CHANGE will ensure internal communication and staff alignment.

4. The Role of Quality in ABCs new Strategic Focus

Inside ABC System our approved QMS (Quality Management System) grants excellence and reliabil-
ity. Outside, new ABC-Quality Gates will set quality requirements and ensure excellence of the
partners. ABC Systems will only cooperate with programs recognized by official institutions such as
the National Diabetes Prevention Recognition Program [8], or programs that pass the ABC Quality
Gates. Medium-term, ABC-Quality Gates will be recognized and serve as certification programs,
granting both our own quality requirements, as well as setting standards for community service
providers and programs.

5. Economic Effects
From the Nurse Health Line Study in 2004, we already know that Changes from patients original
healthcare plans had a potential annual net savings of $322,249. [6] Comparing 2004 healthcare
costs with those in 2013 (interactive Health Spending Explorer [9]), we find figures showing a total
growth of 55.7 % in healthcare costs between 2004 and 2013. In spite of some shortcomings in the
numbers of the study itself, and the projection, ABC System would roughly project estimated annu-
4

ACHE-SETC Student Scholarship 2015 Case Study Claudia Neumann |

al net savings of over $500,000 from the Nurse Helpline alone (!) based on $322,249 savings in
2004 determined by the study, and a growth factor of 55.7% until 2013, disregarding additional
growth until 2015.

Hospitals

Physicians & Clinics Prescription Drugs Overall

2004

566.0

393.3

193.0

1152.3

2013

936.9

586.7

271.1

1794.7

Growth

65.53%

49.17%

45.14%

55.7%

* Figures in US Billions, Percentage calculated from overall figures, varies from arithmetic mean of growth values above (rounding).

On top, there is financial benefit for the patients, indicated in the study with average of $56.77 in
charges avoided per patient. Multiplying these by the NurseLines 30 000 annual patient contacts
yields $1,643,100 in annual charges avoided on the patients side [6].
Potential savings from PHIP disease prevention and control programs can roughly be estimated to
be at least in the annual two-digit billions, since studies about only nutrition and dietary supple-
ment programs effects already arrive at 2.8 8.6 billion of potential annual saving for each of the
different observed conditions [10] by prevention of serious medical interventions. A forecast of the
potential savings of all joint ABC-PHIP programs is part of the analysis of prospective PHIP part-
ners, and exceeds the scope of this case study.

6. Conclusion
ABC Systems shifts towards a strong focus on population health; including and promoting existing
excellent services in our patient care paths. As a not for profit organization, we have the ideal start-
ing point for strong partnerships with outstanding (community) programs, and initiate ABC-Quality
Gates as new standards in population health. We will communicate and promote ABC-PHIP on a
large scale of channels and fight lack of information, a key problem. All program partners and pa-
tients will benefit from this population health strategy financially and in terms of higher quality
health support. Future programs may involve more IT supported, big data driven approaches.
5

ACHE-SETC Student Scholarship 2015 Case Study Claudia Neumann |

Appendix
Illustrations



Figure 1 Population Health [3]

Figure 2 - Comparing US Health Expenditures 2004 vs. 2013 [9]

References

[1] Bill Young, Chris Clark, John Kansky, FHIMSS, CPHIMS, Erik Pupo. (2014). Definition: Continu-
um of Care. HIMSS HIE Committee. Retrieved on July 8, 2015, from [Website]
http://www.himss.org/ResourceLibrary/genResourceDetailPDF.aspx?ItemNumber=30272
[2] David Kindig, MD, PhD and Greg Stoddart, PhD. (3/2003). What is Population Health? Ameri-
can Journal of Public Health, 93(3). Retrieved on July 8, 2015, from [website]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447747/
[3] Editor: David A. Kindig, MD, PhD. What is Population Health? Retrieved on July 8, 2015, from
[website] http://www.improvingpopulationhealth.org/blog/what-is-population-health.html

ACHE-SETC Student Scholarship 2015 Case Study Claudia Neumann |

[4] Dave Chokshi, Nicholas Stine. (1/2013). Defining Population Health: First in a Five-Part Series.
Robert Wood Johnson Found., Culture of Health. Retrieved on July 8, 2015, from [website]
http://www.rwjf.org/en/culture-of-health/2013/01/defining_population.html
[5] Memorial Hermann/Nurse Health Line. Retrieved on July 8, 2015, from [Website]
http://www.memorialhermann.org/emergency/nurse-health-line/
[6] ResearchGate, Gregory M. Bogdan, PhD; Jody L. Green, PhD; Diane Swanson, BS; Patricia
Gabow, MD; and Richard C. Dart, MD, PhD. (9/2004). Evaluating patient compliance with nurse ad-
vice line recommendations and the impact on healthcare costs. The American Journal of Managed
Care. Retrieved on July 8, 2015, from [website]
http://www.researchgate.net/publication/8360449_Evaluating_patient_compliance_with_nurse_ad
vice_line_recommendations_and_the_impact_on_healthcare_costs
[7] United Health Group. Cincinnati (2011). Kroger Joins UnitedHealth Group as a Diabetes Pre-
vention and Control Alliance Partner. Retrieved on July 8, 2015, from [website]
http://www.unitedhealthgroup.com/newsroom/articles/news/unitedhealth%20group/2011/041
9kroger.aspx?sc_lang=en
[8] National Diabetes Prevention/-Recognition Program, Centers for Disease Control and Preven-
tion. Retrieved on July 8, 2015, from [website]
http://www.cdc.gov/diabetes/prevention/recognition/index.htm
[9] Peterson-Kaiser Health System Tracker. Measuring The Performance Of The U.S. Health Sys-
tem, Interactive Health Spending Explorer. Retrieved on July 8, 2015, from [website]
http://www.healthsystemtracker.org/interactive/health-spending-explorer/
[10] Frost & Sullivan. (2014). Smart PreventionHealth Care Cost Savings Resulting from the
Targeted Use of Dietary Supplements. Retrieved on July 8, 2015, from [website]
http://www.crnusa.org/CRNfoundation/HCCS/chapters/CRNFrostSullivan-fullreport0913.pdf