Quality improvement is the science of process management.
Implementation of quality improvement program leads to achieving better care, better outcomes at lower costs – in a sustainable manner. However this requires a process-driven approach, that can be measured and analyzed, course-corrected and optimized in real time to get the best results possible.
Sprite health quality improvement solution marries the pricing data with quality metrics and care pathways to identify the highest value, lowest cost providers for specific procedures and services. This provides the right foundation for quality improvement by systematizing the processes-of-care build around the needs of your population; and measuring, understanding, managing variation and outcomes.
High-priority Process Identification
The selection of high-priority processes can be made at a system, condition or member level.
The system-level process optimization improves quality and cost outcomes for the entire member population. This strategy includes waste reduction which can be achieved through systemic changes that don’t require targeting specific conditions or following specific members. Examples include preventive care, processes to reduce imaging costs, choosing generics over branded drugs, triage systems to move members from ER to outpatient clinics etc.
The condition-level process optimization focuses on high-cost, high-variability, high-frequency conditions prevalent in the member population, such as back pain, maternity, diabetes etc.
The member-level process optimization focuses on the needs of high-risk, high-cost members who are likely affected with multiple chronic conditions.
Waste Identification strategy is based on eliminating quality waste and efficiency waste.
Quality waste means where breakdown in process leads to poor outcomes. Spotting quality waste requires going to the point of breakdown and fixing it to reduce extra services required. In condition-level process, quality waste can be determined by comparing claims data for cohorts with bad outcomes vs. good outcomes. This comparison provides services that are avoidable, and can be prevented if a better intervention/service/program was available earlier.
Efficiency waste means redesigning the process that leads to lower costs for the same outcomes. For example, by choosing Worksite, Telehealth over ER for common issues because of lower cost. Efficiency waste can be based on cost variation for each service or each episode of care.
Evidence-based Care Pathways
Care pathways define predictable course targeting a specific group of members with a specific condition, in which the different tasks or interventions by providers involved in the member care are defined, optimized and sequenced.
When designing pathways, we use the existing resources (benefits) and focus on moving ‘upstream’ for each setting of care. The goal is to provide the ‘right care’, from ‘right providers’, at the ‘right time’ for the ‘right price’.
Our ‘evidence based pathways’ approach focuses on prevention, mitigation and management opportunities for ‘qualified’ conditions in the workplace. For example, in musculoskeletal, the prevention and mitigation includes processes built around ergonomics, employee education, exercise classes, second opinions, conservative therapies and access to lowest cost care.
We tie outcomes to specific interventions. For example, if you have a process around diabetes, should the KPIs be based on more than 50% participation, 10% drop in weight, or 10% reduction in HbA1c, or all of the above? And from the cost outcomes perspective should we look at 20% reduction in pmpm cost for the participating population?
Network design for each ‘qualified’ process should support providers and programs, that are cost and quality efficient, easily accessible, and can work with each other and share data.
This means reorganizing the existing supply-driven health benefits system built around what plans and providers do, towards an employer-driven system built around what the members need.
Our system integrates the best features from each program in your benefits ecosystem and creates unique, personalized, cost and quality optimized care networks for everyone – regardless of their health status, eligibility for benefits, choice of health plan, or work location. For example, if someone is thinking about having a baby, the system can curate, customize and integrate the best services from your maternity program, EAP, smoking cessation, wellness program and medical plan to create a personalized care plan for her to follow through this long journey.
Sprite health provides simplified experience that reduces the amount of effort required on the part of the employee to access programs and information, and make it easy for employees to engage in their health and take advantage of the programs available to them.
Each member interaction with the healthcare system generates data. As the single point of contact for our members, we receive data for each interaction in real time. From these snapshots we are able to see the bigger picture of their healthcare journey. Each snapshot is an opportunity to intercept the member in real time when guidance is essential to improving the member’s outcome. Looking at the bigger picture, we are able to predict future interactions and determine the member’s best course of care. We also pair members with our concierge teams, who work hard to keep members on track by delivering personalized programs directly to their web and mobile apps as a daily checklist.
Analyze and Course-Correct
To build a sustainable learning system, it is important that the processes are constantly analyzed for improvements.
As members enroll and engage, it is critical to collect the engagement and usage data regularly and compare it against the outcomes (the KPIs) to see what services or interventions have had the best impact.
When a pattern emerges that showed a less-than-desirable result, the care pathways can be course-corrected, updated and optimized in real time to get the best cost and quality outcomes possible.
Sprite health also provides tools to check the compliance of all the interventions included in the care plan, and introduce audits as a part of the process. Likewise, we can identify improvement areas in these standardized care processes for continuous quality improvement (CQI).