How Population-Based Care Affects Patient Well-Being

Using an innovative three-tiered approach to population health, Dr. Angelo Sinopoli and Greenville Health System are working to create a healthier, happier community

While many doctors work solely within their hospitals and offices, Dr. Angelo Sinopoli’s work has led him beyond those walls. As the executive VP and chief clinical officer for Greenville Health System’s (GHS) strategic coordinating organization, he’s concerned primarily with population health, which informs the way Greenville engages with and delivers care to its wider community.

The seeds of Sinopoli’s passion for population health were planted early in his career. During his residency at GHS in the 1980s, he developed an interest in pulmonary and critical care medicine after it allowed him to experience various care settings across the continuum. Caring for patients in the intensive care unit, on the hospital floor, and in outpatient settings, Sinopoli witnessed the spectrum of care patients experienced. “You saw what happened to ill patients as they were transferred out to rehab centers or to nursing homes,” he says. “You really got a good perspective of the entire continuum of the healthcare delivery system.”

Later, as the chair of the GHS medicine department, he became involved with hospital case management, working to identify patients that were at risk for readmission to the hospital or poor outcomes after discharge. Realizing this risk was tied heavily to socioeconomic factors that were beyond the control of traditional interventions, the question of whether patients had the resources they needed to care for themselves once they went home further piqued his interest in understanding what happens outside of the hospital.

Angelo Sinopoli, VP and Chief Clinical Officer for Greenville Health System

The development of GHS’s population health approach began roughly ten years ago. With a $2.7 million grant from The Duke Endowment, Sinopoli and his team launched their initial population health pilot, which focused on innovating care delivery for the Medicaid population and other unfunded patients at a resident-run internal medicine clinic. While working to develop a risk stratification process, GHS discovered that 5 percent of the clinic’s patients accounted for roughly 50 percent of the healthcare spend. Of those who frequented the emergency room and inpatient settings, many of the traits they shared were related to their local environment, lack of transportation, lack of knowledge about how to enter the system, and other socioeconomic factors. After discovering these trends, Sinopoli began to investigate new avenues to ensure patients get the right level of care in the appropriate care setting by focusing on care coordination.

“We have to provide that same type of comprehensive care across the continuum with a focus on wellness and prevention.”

This led to GHS creating both the MyHealth First Network (MyHFN) and the Care Coordination Institute (CCI). MyHFN unites more than 2,200 physicians and healthcare providers in one clinically integrated network that spans eleven counties across South Carolina. CCI provides population health services that help networks and health systems deliver efficient, effective care.

MyHFN and CCI are part of GHS’s comprehensive approach to population health, which is composed of three tiers or, as Sinopoli calls them, circles. The first encompasses traditional healthcare providers: physicians and office practices. According to Sinopoli, other delivery systems mainly focus on providing care through this channel. His approach, however, takes things further.

The second circle concerns what GHS calls Patient-Centered Medical Neighborhoods (PCMN). “What we mean by that is partnering with entities that are outside of the typical delivery system to help us improve the health of people in the communities,” he says. This includes partnering with schools, fire departments, and emergency medical services departments, which GHS has worked closely with to reduce the need for people to be transported to the emergency room. Through GHS’s PCMN approach, clinical care is brought directly into the community. Community paramedics and other nontraditional healthcare workers visit patients who frequent the emergency room in their own homes or at local neighborhood sites. For those patients who struggle with transportation and need resources outside of their community, GHS also works to provide alternatives to EMS transport in nonemergency circumstances, and even has an arrangement with a local cab company to transport patients to the hospital or physician offices.

Sinopoli calls the third circle Accountable Communities. “That’s focusing more on the actual community infrastructure itself,” he says. This involves identifying communities that, due to their location and lack of resources, are prone to poor health outcomes and high use of hospital and EMS resources. “We work with them to identify food deserts, lack of transportation, and high crime rates,” he says. “We work with the local Chamber of Commerce and other local resources to help improve this environment and enable residents to take charge of their health.”

Sinopoli is confident this three-tiered approach is the right model for improving population health. “We feel that looking at the delivery system, the clinical resources outside the delivery systems, and then the communities themselves has been a very successful approach to a comprehensive population health program,” he says.

To determine success in that arena, Sinopoli and his team look for an overall decrease in cost of care. And they’ve found it. In just one year, MyHFN decreased the cost of care by $17 million for a group of nearly sixty thousand Medicare beneficiaries through the Medicare Shared Savings Program. GHS did the same for a smaller Medicaid population of about seventeen thousand, decreasing their care cost by $15 million over three years. GHS also uses this approach to manage twenty-two thousand of its own employees and dependents, which has resulted in a decrease of healthcare spending by 5 percent per year. “The quality in all the outcomes and all of these patient populations has also been improved,” Sinopoli says. “Better diabetes control, better hypertension control—that has improved with decreasing costs.”

The future looks bright. Sinopoli notes that GHS is now contracting with regional, national, and multinational employers in the area to provide innovative, population-based care to its employees. “We think that’s the trend of the future,” he says. “We’re going to have to provide that same type of comprehensive care across the continuum with a focus on wellness and prevention, as opposed to waiting until sick patients show up at the ER.”

Sinopoli sees population health working across the country. One of the goals of CCI is to become actively involved in healthcare policy at a national level. Personally, Sinopoli wants it to create a movement across the country to focus on evidence-based programs and get rid of the approach of insurance companies versus delivery systems that results in fragmented care. He says working together to address gaps in care and get patients the care they need to stay healthy and out of the hospital is only the beginning.

It has to start somewhere, however. And that place, evidently, is Greenville, South Carolina.