How to drive a 20% increase in quality metrics in one quarter

Ascension Medical Group advises providers to ‘let your data talk to you’

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Jan 24, 2018

Our recent customer webinar, “A Framework for a Better PHM Strategy: Why You Must Address the Rising Risk Population,” discussed how providers can put the three steps of value-based care – understand your patients, help them navigate to proactive care and activate them to better health – in action.


Cindy Gaines, RN, president–administration, Ascension Medical Group, West Michigan market, described how her organization used these steps to drive higher quality metrics and keep people healthier during a leadership challenge asking all medical groups to improve one quality metric 20% in a single quarter. After reviewing their metrics, the group decided to focus on the uncontrolled diabetic population– those with a hemoglobin A1c level greater than nine.

Media attention

This accomplishment was also recently documented in an article in Healthcare IT News.


The practice used the Philips Wellcentive platform to identify those patients whose diabetes wasn’t under control, then designed an outreach campaign to engage and activate that group. As Gaines explained, “You need to spend time understanding your data. If you do, your data will tell you a story. As providers, we want to jump quickly to solutions, but it’s important to first understand what the issue is.”

PHM: Accountability for patients you don’t see in the office

The most difficult aspect of the challenge was being responsible for patients who were in the panel but weren’t being seen in physician offices. “The shift in population health is that we’re accountable for patients across the continuum whether they come into our office or not,” noted Gaines. “Their diabetes is considered uncontrolled if we don’t know what their hemoglobin A1c is.”


The Philips Wellcentive platform helped Ascension Medical Group at Borgess identify the patients they needed to reach and then engage them to come in for care. Of the 2,600 patients whose diabetes were poorly controlled, more than two thirds hadn’t been seen in the past year. The team needed to find a way to effectively reach out to these unengaged patients and activate them to better blood sugar control in a short time. Each of the 19 primary care practices had their own ideas about how to best reach their patients.

The results of outreach … and beyond

Gaines said, “We allowed each group to pick one outreach tactic in the pilot/challenge period – including portal messages, electronic calls and calls from pharmacists and care managers. While all tactics were fairly effective, we found that outreach via the care managers was the most effective strategy, activating some 35 percent of unengaged patients. Having a pharmacist call these patients was the second most effective strategy.”


While having care coordinators make calls had the best results, they learned that it was not the most cost-effective strategy and was not using these professionals to the top of their license. After evaluating the challenge period results they piloted a ‘panel coordinator’ position that used a medical assistant to focus on engaging patients.


The results were impressive. At the beginning of the challenge period, 29 percent of patients were uncontrolled. After three months, they surpassed their goal of decreasing this number to 23.2 percent and reduced the uncontrolled patients to 19 percent. Next, they set a goal of 15 percent, which they have now maintained for three years.


The following year, six of their primary care practices became recognized in the top 20 percent of quality performance in the Blue Cross Blue Shield of Michigan incentive program.


Gaines concluded, “While it was initially hard to get providers to trust the data and use it to improve quality, today, it has become second nature and these practices have hardwired this approach to patient care.”


Want to learn more about how providers are using the Philips Wellcentive PHM platform for value-based care success?

  • Watch the webinar
  • Read our white paper, “Beyond Frequent Fliers: Why Health Organizations Need a Comprehensive PHM Strategy”
  • View a short video interview with Cindy Gaines

About the author

Cindy Gaines

Cindy Gaines,
Chief Nursing Officer


Cindy Gaines has over 28 years of healthcare experience, splitting this time between quality and operations across the continuum. During her esteemed career, Cindy has led the integration of patient care across the care continuum and integrated program requirements of third-party payers including pay-for-performance criteria to maximize clinical, operational, and financial initiatives.

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