Edison, NJ (December 2, 2020) – Spring Hills today announced its plan to begin expanding its population health management program to reach more patients and to leverage an integrated, patient-centered, IT- and AI-enabled care delivery system. Led by Dr. Pierantonio Russo, the newly appointed Chief Medical Officer and Chief Clinical Transformation Officer, the program will be integrated into all of Spring Hills’ clinical programs, post-acute care communities and home care services to offer patients and residents uniquely comprehensive health services and support. In addition, Spring Hills will partner with medical groups and health plans to provide patient-centered population health management services to their patients and members.
“As Spring Hills adds clinical programs, it is essential that we position both our patients and the programs for success,” said Alex Markowits, Founder and President/CEO. “Comprehensive population health management directly supports clinical treatment plans by filling the costly gaps in care that can derail a patient’s journey from hospital to home and better health. It is a key part our plan to improve health outcomes and provide measurable benefit for our patients, providers, and payer partners.”
Spring Hills Population Health includes the design, delivery, coordination, and payment for high-quality health care services using the best resources available, including accountable care organizations (ACOs), risk stratification methods, patient registries, and patient-centered medical home and other models of team-based care.
An increasingly influential approach, population health management addresses all the factors that influence an individual’s health. This includes social determinants of health — social, economic, and environmental issues — as well as behavioral factors that can impact health and adherence to medical treatment. Data has shown that these factors contribute to more than half of health outcomes. Population health management professionals work with the patient, family, physicians, and payers to design an integrated plan of care tailored for the individual and delivered in the most appropriate setting. Further, they ensure that the patient and family have the education and support they need to adhere to the plan of care.
“Comprehensive population health management fills critical gaps in the patient journey,” said Dr. Russo. “It also provides connective tissue for our fractured healthcare system. Advanced information technologies (IT) and artificial intelligence (AI) allow us to anticipate the likely course of a patient’s health condition and create a care plan to bypass known risks and meet – or even pre-empt – their needs. Further, these technologies allow for scaling best practices of care to fulfill the requirements of value-based and bundle reimbursement contracts.”
Focusing on defined groups of patients with common medical conditions and risk factors, Spring Hills Population Health will leverage machine learning algorithms that allow personalized engagement and targeted interventions along the continuum of care. Specifically, the program will offer initial patient assessment, including the identification of unmet social needs; risk stratification for clinical, social, behavioral, and medical cost factors; integrated case management; comprehensive education; digital case management and continuous patient engagement; remote monitoring of physiological parameters and telemedicine; coordination of medical transportation; urgent care visits; mobile care; and palliative and hospice care.
Spring Hills intends to grow the program by engaging data consultants and partnering with health systems and payers, care specialists, and social service providers. Its team will leverage technologies that streamline communications and care provision to provide comprehensive population health services to patients enrolled in the program.
“We vet all of our preferred partners and hold them to our high standard of care,” said Gloria Berwick, Vice President of Operations for Spring Hills Population Health. “We create integrated workflows, have weekly meetings to discuss our common patients, and require monthly reports on outcomes. Maintaining open, regular channels of communication with our partners is as important as our clinical teams’ doing so with patients’ own physicians and caregivers. Ensuring that we all stay aligned around fulfilling the patient’s needs is what patient-centered care is all about.”
Fully integrated into their multidisciplinary medical teams, Spring Hills Population Health associates build relationships with the patient and family while in the hospital to ensure a smooth transition to Spring Hills and provide support during their stay and for 90 days post-discharge. Services include coordination of care, intense engagement with the patient and caregiver through personalized communication channels, home visits, remote monitoring, and addressing and removing social and financial barriers to access to care. Through population health management, Spring Hills keeps its average rate of hospital readmission after 90 days under 10% — far lower than the national rate of 23-27%.
While currently focused on building programs in New Jersey, Spring Hills intends to scale its population health management program to support the provision of health care across the organization’s care continuum. Spring Hills operates 28 communities in 7 states.
Markowits shares his thoughts on population health and the future of health care in his blog.
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About Spring Hills:
Spring Hills Post-Acute Care, Assisted Living, and Memory Care communities and Home Care services provide comprehensive support, including population health management, for seniors and those with chronic health needs. All communities have a personal and distinctive approach and ensure the highest standards for proactive health care and quality of living, at every stage of a resident’s life.
Led by Alexander Markowits, Founder and President/CEO, Spring Hills is committed to providing seamless care experiences that meet the unique needs and preferences of residents, patients, and their families. Spring Hills has 28 facilities across seven states: Post-Acute Care in NJ; Assisted Living and Home Care in NJ, NY, VA, OH, FL and NV; and Memory Care in TX, VA, NV and FL. For more information, visit www.spring-hills.com or www.poetswalk-springhills.com.