Population Health in Indiana: Second in a Series

Population Health

A Look Inside: The Design, Organization of Integrated Networks

The days of filling hospital beds and amassing physician office visits are coming to an end for two budding Indiana initiatives built around anticipating all the ways they can keep people out of medical trouble and out of the hospital.

For St. Vincent Health, a 20-hospital system based in Indianapolis, teams of professionals have been mobilized to monitor people both in the clinical setting and in the community to make sure they can follow day-to-day instructions for managing diagnosed conditions and not suffer health declines. That includes measures to surmount all manner of hurdles–physical, social, behavioral and environmental.

For Columbus Regional Health and Schneck Medical Center in Seymour, operating in adjacent service areas in South Central Indiana, an agreement to integrate their organizations includes expanding the aims of primary care to encompass mental health, exercise and nutrition, and specialty services that belong closer to the action rather than separated by a traditional referral process.

Both efforts center on building a clinically integrated network, which powers very different and more comprehensive approaches to care delivery in a world of value-based performance and payment. Gone are the relatively straightforward norms of practice:

  • Patient gets sick or injured, visits doctor, gets medical treatment, perhaps is referred to a specialist, fades into the background and either gets better or comes back.
  • Really sick patient gets admitted to hospital, gets treatment and is discharged with a ton of instructions, maybe a perfunctory follow-up call within a week.

Those traditions of interaction with patients leave yawning gaps in a health care organization’s ability to thrive under emerging Medicare and commercial payer models based on responsibility for overall health status and cost efficiency in return for finite reimbursement per person over a set length of time.

To put health care organizations on the path to vigilant monitoring and quick response to the ills of a population for which they’re accountable, the whole emphasis of health services has to shift from hospitals, emergency departments and traditional physician offices to a new integrated structure for preventive and community-facing care, including the patient-centered medical home as a centerpiece.

“We need to have wellness programs, we need to have employer clinics, we need to have (favorable) employer benefit plans,” says Marc Rothbart, president of Inspire Health Partners, a clinical network that is organizing the Columbus and Schneck medical communities. “We need them all supporting the mission of the patient-centered medical home and what the medical community is trying to accomplish. Right now all those things are disjointed.”


One of the first objectives to turn disjointed efforts into close coordination of patient interaction with the health system is to take on inefficient or inattentive transfers from one care setting to another, says Richard Fogel, M.D., chief medical officer for Indianapolis-based St.Vincent Health. “Transitions are going to be the cornerstone of any population health management program,” he asserts.

A transitions-of-care team is a proactive addition to the St.Vincent Health drive for patient-centered services. These teams ensure that post-hospital follow-up appointments are timely and kept, and they confirm that patients are on the proper medications and that they actually receive and take the medications.

Another force for vigilance is the ambulatory team, charged with keeping people out of the hospital. Team members are assigned to individuals with, say, multiple chronic diseases, identifying and/or supplying support services for a given disease, such as diabetes, and informing all physicians about what each of them is doing concurrently for patients in common, says Fogel.

A third team, for integrative care, is designed to remove psycho-social barriers. Social workers tap community resources available to help people who, for instance, don’t have a way to get to a medical appointment or can’t afford medications and aren’t aware they can get a discount or subsidy.

Though focused on patients’ community-oriented challenges of recovery at home or staying healthy, the various teams also keep in touch with hospitals and ambulatory networks on the clinical side, says Rebecca Adkins, population health consultant at St.Vincent Health. The organization contracted to operate the community effort, MissionPoint Health Partners, began this summer to embed ambulatory teams in physician offices. If someone calls the office to perform a significant task on behalf of a patient, such as medication reconciliation, the embedded professional is there to field the request, says Adkins.


Inspire has 11 medical home units operating in the communities of Columbus and Seymour, with ambitions to expand and tailor the professionals within them to accomplish care objectives more completely than in the past and also take on new objectives through work roles that haven’t been associated with primary care until now.

One component covers the preventive and wellness objectives of caring for people under any sort of financial risk, which calls for roles such as exercise and nutrition counselors, says Rothbart. That squares with a trend toward bringing a range of expertise into the medical home sphere, enabling immediate input and quick treatment of ills that the medical home unearths but might go untreated if left to a separate and time-wasting referral routine, he says.

Other examples include specialties that should be more mainstream for patient-centered care, especially mental health services. Rothbart says it would be cost-prohibitive to place mental health care providers in all medical homes, but he’s looking for creative ways to establish partnerships. One option is to have the same mental health clinicians in a community work with a given medical home to attend to behavioral health issues affecting primary care. Primary care physicians, conversely, could be trained to streamline intake of patients needing mental health care, he says. The new roles require thoughtful division of responsibilities and protocols that alter the norm of physician contact with basically every patient. The protocols delineate “who in the office should be taking care of what pieces,” Rothbart says. Instead of routing everything through physicians, there are nurse practitioners, medical assistants and others attending to gaps in care plans, leaving doctors to deal with patients needing the most attention—with the necessary information assembled by staff to have a productive conversation.


The upshot of all this extra effort is a connected continuum of coordination starting in the hospital and fanning out to medical homes; other community sites of care, such as workplaces or social agencies; pre-emptive actions in patient homes; and containment of health decline such that people don’t end up back at the hospital. That takes structure and deft deployment of personnel.

St.Vincent Health transition team members, for example, get an alert from a clinical IT system within 15 minutes of when a MissionPoint patient shows up at one of the St.Vincent Health hospitals or emergency departments, says Adkins. That starts the patient-centered pathway and their involvement with that patient.

The software system also performs risk stratification, so the ambulatory team can know who is getting sicker and who is at lower risk, and they can develop outreach and wellness campaigns around that information. Integrative care interweaves with ambulatory care activities. If an ambulatory care team member working with a patient reports issues around getting to a physician office, “an integrative team member is right there in the office” and immediately gets involved, Adkins explains.

MissionPoint pros stay on the same course as clinicians regarding care plans for a particular patient. On the ambulatory side, they have access to medical record information, or they can sit in on office visits to hear what the care plan is and the best way to execute it. On the inpatient side, they get the discharge summaries, and they’ve also met with the patient’s case manager, Adkins says. “Their job is to execute that discharge plan, make sure that happens for the patient and remove any barriers.”

Next in the Series: How Clinical Integration and Community-Focused Initiatives Drive Accountable Care