Volume 1, Issue 1 – January 2019

1 Improving Health Care with Population Health

Nurse helping patient

How Dignity Health is finding the best ways to care for our patients.

Population Health Definition

The Jefferson College of Population Health describes population health management as: “Population health activities … connect prevention, wellness and behavioral health science with health care delivery, quality and safety, disease prevention/management and economic issues of value and risk — all in the service of specific populations, particularly at-risk populations and sub-populations.”

At Dignity Heath, population health management centers around the Quadruple Aim of Health Care. To optimize our performance, we focus our efforts on:

  • Improving outcomes. Successfully treating both our individual members and our overall population.
  • Lowering costs. Reducing waste, length of stay, and other factors that affect the bottom line.
  • Creating a better patient experience. Meaningfully engaging with members and their families and making their interactions and environment as positive as possible.
  • Improving the clinician experience. Making sure providers are able to do their best work and avoid burnout.

Our Population Health Management program is dedicated to ensuring individual patients’ needs are met with extraordinary care. At the same time, our Community Health team works to build strong partnerships to address social, behavioral and medical determinants of health such as housing, access to healthy food, safe places to exercise and more.

Where these two missions overlap, we see a distinct opportunity to enhance the overall health of the communities and populations we serve.

Over the last six years, Dignity Health has invested heavily in the infrastructure to support our population health activities. Our goals are to assure that:

  • Patients receive care across the continuum
  • Patients’ transitions in care — for instance, between going from hospital discharge to home — are well-managed
  • Patients with multiple illnesses or “co-morbidities” receive extra attention and care coordination to assure they remain as healthy as possible
  • Patients receive care in the right setting

With programs and initiatives dedicated to these goals, we are able to improve our patients’ care experience — making it less disjointed — while also improving the overall quality and efficiency of the care we provide.

“When populations are healthy, we all win. A focus on healthy populations creates a backdrop for enhanced quality of life for those we serve. Dignity Health is improving health outcomes in the broadest sense by focusing on access to care, health education, disease management and prevention, and the social determinants of health. We see population health management and healthy populations as inextricably linked.”


2 Humankindness

Grandpa hugging grandchildren

Ed* is a 51-year-old business owner who’d been focusing all his efforts on helping his business succeed — until last July when he suddenly wasn’t feeling well, that is. That’s when Ed’s Dignity Health primary care physician referred him to Care Coordination to help get his type 2 diabetes back under control. (Prior to this, Ed’s last PCP visit had been in October 2015, when he had an A1c of 9.7. Normal A1c in people without diabetes is below 5.7 percent.)

He began working with his care coordinator via in-home visits, where he received diabetes supplies and education, and learned to use his glucometer as well as monitor and document his blood sugar and blood pressure and take his medications correctly. Ed’s care coordinator also worked with him to help him adopt lifestyle changes including quitting smoking, reducing his alcohol intake, eating a healthy diet, and walking on his treadmill five days a week. By the time he’d graduated from the program in February 2017, Ed had transitioned to monthly phone support and in-home visits as needed — and achieved an A1c of 7.0.

*Name has been changed to protect patient privacy.

3 What Is a Clinically Integrated Network?


A clinically integrated network (CIN) is a network of health providers — including doctors, hospitals and others — working together using proven protocols and measures on initiatives designed to enhance care quality, better coordinate patient care, improve efficiency and lower costs. Dignity Health has eight CINs in Arizona, California and Nevada.

4 Value-Based Care and MSSP

How a shared savings program is helping to drive our Population Health programs.

Many health care organizations across the country are changing the way they are reimbursed by payers — going from a model based on services provided (fee-for-service) to one that’s focused on health outcomes (value-based). Dignity Health has been a leader participating in value-based programs like the Medicare Shared Savings Program (MSSP) to help make this shift.

Here’s a quick primer on MSSP — what it is and how it’s helped align our quality measure and enhance our reporting, which lets us both improve how we’re doing and track our progress.

What is MSSP?

MSSP is a voluntary program designed to deliver better health outcomes (for individuals and the population as whole) and lower costs by encouraging doctors, hospitals and other providers to create an accountable care organization (ACO) to provide well-coordinated, high-quality care for their Medicare patients.

How we participate in MSSP

Dignity Health has formed five ACOs in Arizona, California and Nevada serving nearly 100,000 Medicare patients. Our MSSPs focus on improving care and outcomes, improving efficiency and reducing costs. As of the MSSP process, we also submit data on 31 quality measures.

These quality measures are tools that help us quantify our overall health care processes to improve our performance as well as health outcomes. For example, we can measure how we perform on things like ensuring that our populations get their flu shot. Meanwhile, outcomes show us the results, such as lowered A1c levels by following measures and protocols for diabetes care.

Our MSSP participation has helped our Dignity Health clinically integrated networks put an increased focus on collecting this quality data and reporting it back to physicians to help guide them. This data helps us meet MSSP program requirements and moves us forward in our quest to accomplish the Quadruple Aim.

5 Five Things You Should Know about athenaHealth

Doctor writing down information

athenaHealth is a cloud-based tool we use to manage the care we provide to our patient population. The Population Health Management team uses it to identify high-risk patients, coordinate care and monitor quality and outcomes.

Here are five things to know about the platform:

  1. Lots of data sources. This system brings together data from hospitals, urgent care centers, payers, labs, electronic medical records and more, which helps us get a more complete picture.
  2. Tracking care coordination. We use it system-wide to track our care coordination outcomes and successes — and to identify areas that might need more resources.
  3. Tracking quality. We use its quality measurement tool to track members, document information and generate reports. This data can help us decide where to invest resources, expand programs and explore opportunities for cost efficiencies.
  4. Analyzing the data. The reports and dashboards we create with athenahealth provide information that helps us understand our population and set goals. We can easily track annual wellness visits, inpatient and emergency department utilization, high-cost and high-risk members, and more.
  5. Risk stratification. With athenaHealth’s risk stratification tools, we can identify higher-risk members, enroll them in disease management programs, document their interactions with providers and make better care decisions. We can concentrate resources where they can do the most good for the overall population.

6 Did you know?

We have more than 8,000 clinically integrated clinicians, 90% of which are community physicians. This includes both employed and independent physicians across Arizona, California and Nevada.

7 Meet the Pop Health Team – Q/A

Nicholas Stine

Get to Know the Team: Dr. Stine

The Population Health Management team is spread out across three states, and our roles vary from data and analysis, to strategy, to digital development, to clinical. Nicholas Stine, MD, Senior Medical Director for Value-Based Care for Dignity Health, interacts with all of our teams — and is helping to drive our mission forward.

Q. Why did you decide to move to California and to join Dignity Health?
My wife and I were living in New York City with my oldest son Owen, and then we found out we were expecting twins. I was excited about the opportunity to be a part of this dynamic organization, where I could work on how to address the health of millions of people, teach residents and serve patients too.

Q. What is your role within Population Health?
I see our work as helping to layout a path toward moving Dignity Health away from a fee-for-service payment system to a payment system based on value and population health. It’s a fundamental shift and long-term commitment. Day to day, we’re engaging with leadership across different service areas in the system, both clinical and operational, to build up their understanding of where we’re going. We’re also helping to guide them toward data-driven strategies that are aligned with what’s needed in their communities.

Q. What do you love about your job?
I’m a mission-motivated person, and the potential impact of shifting this very large system to a different paradigm — and the impact that it would have on millions of people — is really exciting. I also like the diversity of my jobs; there are a variety of challenges I get to think about.

Q. How do you think Dignity Health might look in the future as a result of the work of Population Health Management?
I think we’re going to see a lot more services embedded in our communities. Our work increasingly extends beyond the hospital walls. There will always be a need for hospitals, but I think it will be a more community-embedded organization with its heart and soul in the outpatient setting.

Q. What are you doing when you’re not working?
My wife and kids — my 3-year-old and 10-month-old twins — are my life. It’s just incredible to watch them grow and to see our family becoming a somewhat organized circus. It’s crazy — and totally joyful.

8 Final Word

“As we continue our journey from a hospital organization to a clinically integrated care management enterprise, focused on population health and related outcomes, we are very proud of what we have accomplished in a relatively short amount of time. We are committed to maintain our laser focus and speed towards our overarching goal: To improve the lives of our patients in the communities we are privileged to serve.”

– Bruce Swartz, Senior Vice President, Physician Enterprise

9 Our Mission

Our mission is to provide health care that improves the well-being and quality of life for the individuals and communities we serve.