Evaluating our Programs
Population Health manages our system’s investment in care transformation by evaluating the impact of our population health management programs on patient and provider experience, clinical outcomes and health care costs. The Evaluation and Research Unit conducts and supports effectiveness evaluations of the population health care delivery transformation projects sponsored by Population Health.
The Evaluation and Research Unit works collaboratively with program implementation teams to design approaches that allow for robust evaluations, actively supporting the use of pragmatic trials when possible. The majority of program pilots are embedded within our delivery organization and rely on data collected during the routine provision of care. While our primary objective is to support internal decision making and quality improvement, many evaluations are externally disseminated as well. Examples include:
- The integrated care management program is effective at reducing health care utilization (non-emergency and all ED visits, hospitalizations) and reducing costs of care for Medicare beneficiaries in the Mass General Brigham Medicare Accountable Care Organization (Hsu 2017). However, significant changes in beneficiary alignment from year to year remain challenges to program implementation and investments (Hsu 2016, Hsu 2017).
- Patients are selected for high risk care management using a hybrid approach in which primary care clinicians review algorithm-generated lists of potential high-risk patients to identify patients for the care management. Clinicians reported considering both patient clinical need and predisposing (e.g., health literacy or navigation challenges, physical vulnerabilities, insight regarding their health) and enabling characteristics (e.g., social and home environment, coping skills, financial resources) (Haime 2015). Overall, primary care clinicians were more likely to select patients who were older and poorer from the algorithm generated lists. Significant variation in the importance of specific characteristics across primary care practices may reflect differences in practice resources, or could reflect bias (Vogeli 2016).
- The skilled nursing facility (SNF) transitional care management program was associated with, on average, 4.9 day shorter skilled nursing facility stays in a propensity matched retrospective evaluation among patients discharged from five Mass General Brigham acute care hospitals (Pu, 2019)
- A pilot randomized control trial of home hospitalization found that costs for the home hospital episode (acute care plus 30 days) were 67% lower among patients randomized to home hospital relative to patients randomized to receive traditional acute inpatient care (Levine 2018). The home hospital program has expanded to new indications, and additional findings are forthcoming.
Collaborating on Research
Population Health programs are a natural laboratory for studying health care transformation and to understand variations in implementation and effectiveness within a diverse health care system. While most evaluation activities are funded by Mass General Brigham, we also collaborate with the research community on external funding applications. To date we have received funding from the Patient Centered Outcomes Research Institute, the National Institutes of Health, and foundations. Collaborative research opportunities include implementation science, program evaluation and observational research related to population health.
We are eager to collaborate with other regional and national organizations involved in similar health care transformation efforts.
Sharing Best Practices
Population Health is committed to shared learning and using best practices.
The Research Symposium is held annually to foster shared learning and collaboration across the system. It is a forum of leaders in clinical transformation and research to network and understand opportunities for collaboration. Past Symposia have included poster sessions, rapid fire research presentations, didactic sessions, and national speakers on implementation science and embedded research. Learn more about the 2019 Population Health Research Symposium.
Implementation teams are supported by world-class integrated data, implementation scientists and methodologists located with Mass General Brigham and its academic affiliates. Centrally, implementation teams are supported via:
- Logic Model trainings
- Guidance on implementation design
- One-on-one poster reviews
- Survey development expertise