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Population Health

Quality Management

Improved care. Improved health. Reduced cost. Innovation at the Temple Center for Population Health is dedicated to pursuing the triple aim of healthcare. That drive undergirds all Temple Health operations and partnerships—and our quality management programs are the means by which we achieve it.

Quality management initiatives at the Center for Population Health allow us to advance care, keep patients healthier, and make sure that everything we do adds value. Much of this work focuses on pay-for-performance and alternative payment models guided by our health plan partners. These models provide a means for investment in optimizing patient outcomes as measured by HEDIS, CMS Stars and similar programs. We work with provider partners to:

  • Enhance health equity and close care gaps
  • Reduce health care costs and over-utilization
  • Ensure patients receive appropriate treatment, screenings, and follow-up for key conditions or health challenges
  • Address the causes of hospital readmissions and improve transfers in care

Tracking What Matters

Tracking key performance indicators (KPIs) across different areas of practice through Epic and other electronic health record systems allows us to continuously improve.

Healthcare Effectiveness Data and Information Set (HEDIS) measures cover many areas of quality and safety—from hospital readmission rates to percentage of patients in at-risk groups receiving appropriate screenings or vaccinations, to whether patients’ blood pressure is adequately controlled. They are used by the majority of health plans in the United States to evaluate care performance and quality. In addition, TCPH programs track measures relevant to CMS Star Ratings for Medicare-sponsored plans as well as other payer partnerships.

We also conduct risk assessment, working with each payer’s specific system for encoding patient health risk factors to determine a patient’s level of overall health risk and appropriate responses.

Quality measures tracked by TCPH programs include:

  • Blood pressure control
  • Blood sugar control (A1c)
  • Annual eye screening
  • Colon cancer screening

Alternative Payment Models

Using these data, Temple Health and affiliated providers and health plans can work to improve care as well as implement innovative alternative payment models (APMs). APMs seek to enhance care quality and reduce unnecessary costs through pay-for-performance/value-based care. Unlike traditional fee-for-service models, APMs incentivize improvement and hold health care providers financially accountable for effectiveness and efficiency. For example, bundled payment mechanisms may promote cost-effective care and interventions while requiring or financially incentivizing high-quality care or key outcomes. Certain APMs allow Temple and affiliated providers the flexibility to invest in high-impact programs like patient navigation, community health workers, and proactive screenings.

Whole-Person Care and Performance Improvement

In addition to tracking Temple University Hospital outcomes, TCPH quality management staff act as a bridge between payers and affiliated patient-centered medical homes, working with health plans and provider offices on quality improvement initiatives related to alternative payment models such as Primary Care First and other voluntary CMS programs, as well as shared risk agreements. In concert with Temple’s community partnerships and Care Management programs, we ensure that care and screenings are proactive, delivered in compliance with high performance standards, and built around the needs of each patient.

Care Management
  • We set patients on the path to recovery rather than readmission. We work to ensure that high-risk patients who have been admitted to any local Pennsylvania hospital receive a transition-of-care visit with their primary care provider within seven days after discharge.
  • We run self-monitored blood pressure programs that work with patients to proactively manage their blood pressure and prevent adverse events.
Accessible Care and Screenings
  • We increase the accessibility of care by offering telemedicine options for transitions of care visits, annual wellness visits, and more.
  • We screen as many patients as possible for social determinants of health, such as transportation, food, housing, financial security and healthcare literacy (and provide follow-up services/resources where appropriate).
  • We partner with Fox Chase Cancer Center and other Temple campuses to increase cancer screenings.
  • We provide behavioral health management and screenings, especially for patients with chronic conditions that may be exacerbated due to underlying depression or anxiety.
Process Improvement
  • We work with primary care providers using Optum data to ensure that high-risk patients or those with multiple chronic conditions are enrolled in care management programs and receive disease-specific information.
  • We provide resources to providers to help them appropriately code and manage patient information in electronic medical record systems to enable more informed, effective, and efficient care.
  • We help ensure that primary care providers receive behavioral health information to inform care plans.

Our quality management work also helps us prevent adverse outcomes among patients with chronic illnesses such as COPD, diabetes, and heart failure. Tracking patients over time allows us to understand the factors contributing to severe disease and address barriers to compliance, empowering both patients and their providers to manage health conditions and reduce the need for hospital visits.

The Temple Center for Population Health never stops working for better health and health care.