St. Joseph’s Health: Leveraging the Continuum of Care to Improve Population Health

By Kaitlin Gunter
Wednesday, June 21, 2017

St. Joseph’s Health offers a comprehensive range of health services — from home-based and community-focused programs to well-established hospital and primary care programs — to track patient progress and secure better outcomes through a continuum of care.


A St. Joseph’s Home Care nurse helps a patient with daily intravenous antibiotics.

By moving away from the pay-for-service model and toward people-centered care, St. Joseph’s Health changed the way they approach medicine and took a proactive view of treatment. While the old model relied heavily on inpatient health resources operating at a high cost, the new patient-centered model allocates resources to lower-cost outpatient care services, transitioning patients more naturally from outpatient to inpatient as needed, tracking health outcomes along the way and ultimately maintaining patient well-being through improved patient engagement.

Laying the Groundwork

For many hospitals and health systems, the journey away from the pay-for-service model is a slow, cumbersome undertaking during which top healthcare executives are tasked with rebuilding infrastructure, reorganizing teams of physicians and remodeling patient care plans to account for more primary care touch points. Pioneering a vision for population health management decades before it turned into a health reform movement, St. Joseph’s Health made a long-term investment in building a more effective healthcare delivery system.

St. Joseph’s Health started putting a continuum of care model into place in 2012, formalizing and localizing the concept of population health management and establishing a network of care that functioned efficiently, with safety, quality, technology and clinician competency as the underlying foundation.

Within this model, patients are not cared for in an episodic fashion, but rather proceed through a continuum of medical care, transitioning seamlessly to the appropriate provider at the appropriate time within a wide, integrated network while a sophisticated shared EHR system tracks interactions and outcomes, explains AnneMarie Walker-Czyz, RN, EdD, NEA-BC, Senior Vice President for Operations and COO/CNO of St. Joseph’s Health. Access to patients’ EHRs provides clinicians with a complete picture of their care progression and allows for seamless continuity of care.

St. Joseph’s Health Launches 150th Anniversary Capital Campaign

John Merola, MD, kicked off fundraising efforts with a $3 million gift.

St. Joseph’s Health recently announced the details of its $20 million 150th Anniversary Capital Campaign. This is the organization’s most determined philanthropic endeavor yet, with key projects in three critically important areas: cardiovascular, breast care and nursing education.

John Merola, MD, Cardiovascular Center of Excellence at St. Joseph’s Health

The initiative’s touchstone component is the construction of a new Center for Cardiovascular Care that will allow the hospital to truly become a destination center for all cardiac services

Dr. Merola is Honorary Chairman for the 150th Anniversary Campaign and has generously donated a $3 million contribution toward this project.

Breast Care and Surgery Program

As part of an advanced Breast Care and Surgery Program, St. Joseph’s Health has acquired a 3-D Imaging Unit and Workstation to provide an enhanced level of care in collaboration with affiliate St. Joseph’s Imaging Associates.

College of Nursing

St. Joseph’s College of Nursing was established in 1898 and became the main resource to secure quality graduate nurses for the hospital and healthcare facilities in the region and beyond.

For more information on the 150th Anniversary Capital Campaign and each of the individual initiatives, visit sjh150campaign.org.

The Heart of the Patient Experience

Patient care can take a village. Inclusive network access to appropriate healthcare professionals and supportive services helps ensure patients are positioned to appropriately self-manage their health needs outside of an acute setting. At St. Joseph’s Health, that support structure includes a system of outpatient behavioral health services and programs, as well as certified home health and community-based care providers. Simplifying access to supportive services makes patients more likely to take advantage of them.

“These services provide a safety net for patients between their contact with primary care physicians and other specialists on their care team,” says Mark Murphy, Senior Vice President for System Development and Ambulatory Care Administration, St. Joseph’s Health.


Kara Kort, MD, performs a thyroidectomy

This gray space of care, as Murphy refers to it, is no longer a potential gap in patient care. Now, it falls in line with the overall population health structure, as each support service team member is able to maintain contact with the patient’s primary care provider. This ongoing conversation between the primary care provider and the patient is paramount to health management and the ultimate goal of reducing the need for inpatient admissions.

HealthWise Health Coaches, a part of the St. Joseph’s Health platform since 2013, helps make this goal possible by eliminating barriers to health care and ensuring patients have appropriate access to fill prescriptions, transportation to appointments and the information they need to effectively manage their chronic conditions. St. Joseph’s Health recognized the need for health coaches early on and stands apart in the vigor it extends toward integrating these services under the continuum-of-care umbrella.

The benefits of this system are particularly clear while managing patients with conditions such as congestive heart failure or chronic obstructive pulmonary disease. These patients are transitioned from acute care to home health services, where nurses provide education, review their progress and connect patients with primary care health coaches who further encourage them to make lifestyle and behavioral health changes as they work toward personalized health goals. If there are signs of recurrence or worsening of symptoms, nurses and health coaches facilitate early intervention to minimize the need for acute care. If the situation warrants additional specialized care, patients continue to access network providers who meet their changing needs through the St. Joseph’s Health continuum of care — a perfect marriage of population health with well-established hospital programs.

Raising the Bar

A natural result of the focus on population health at St. Joseph’s Health, the system has earned many recent merits, including:

  • Greater patient satisfaction: Awarded a smart rating of 88 by Health Grove, while other area hospitals earned an average of 71.
  • Fastest growing hospital: Performing more adult surgeries than any other area hospital, St. Joseph’s Health has been the fastest growing hospital in Central New York for the past five years.
  • Magnet designation: Recognized for excellence in nursing in more than 35 areas of focus by The American Nurses Credentialing Center (ANCC), St. Joseph’s Health is currently the only Magnet-designated hospital in Central New York.
  • First in the region for robotic surgeries: Performed more robotic procedures than all five other area hospitals at the close of 2016.
  • Orthopedic excellence: Performed more elective orthopedic operations than any other hospital in the region — over 10,000 since 2010.
  • Vascular excellence: Named the No. 1 hospital for vascular surgery in New York State and among the top five percent in the nation by Healthgrades.

Investing in the Full Continuum

St. Joseph’s Health has invested heavily in developing a comprehensive acute care program that marries leading-edge technologies to highly skilled clinicians who address the needs of patients undergoing unexpected acute events or changes in their chronic conditions.

“We have made targeted investments in the comprehensive care of our populations of patients, whether they are at home, receiving outpatient care or in the hospital setting,” Walker-Czyz says. “We’ve expanded our offerings and use the safest, most cutting-edge technology available to providing the highest quality of care and safety we possibly can, while still being able to facilitate complex interventions.”

The continuum of care at St. Joseph’s Health makes preventive health convenient and affordable. Patients have access to cost-effective health resources and are well connected to their primary care providers so they are better able to self-manage their conditions. These deep and meaningful relationships result in targeted, meaningful outcomes and allow patients to make fiscally responsible healthcare decisions with the appropriate input and support.


Mark Charlamb, MD, and Anne-Marie Czyz, Senior VP of Operations and COO/CNO of St. Joseph’s Health

As St. Joseph’s Health continues to partner with patients, providers also receive key benefits. More patients have the knowledge and resources necessary to self-manage their health, freeing primary and acute care providers to prioritize care of patients with the greatest medical needs. Smoother patient transitions from point-to-point along St. Joseph’s Health’s continuum of care reduce patient volume in higher cost settings, granting providers more time with patients. The population health model enables providers to fine-tune their involvement in the continuum of care, establishing the most valuable points along the care path for them to interact with patients.

“We will likely see some health providers and staff move from practicing only in the acute care setting to offering acute care and health coaching or shifting more into population health-focused roles,” says Leslie Paul Luke, President and CEO, St. Joseph’s Health. “This gives them more personal sustainability in their careers. In the past, roles tended to be extremely specialized, and that’s good to an extent. But in the future, the more skill sets a provider has, the more valuable that person becomes to patients and health centers.”

While the continuum of care reinforces the need for specialized clinicians, it also encourages them to broaden their level of competency to better address fluctuating patient needs as individuals continue to transition to more appropriate levels of care under the structure of population health management, Walker-Czyz adds.

Feasibility and the Bottom Line

By undertaking and successfully implementing the continuum of care, St. Joseph’s Health established the feasibility and benefits of this model in today’s healthcare environment, even as many other institutions are just beginning to lay the groundwork for community-based programs. Such groups face many hurdles to their progress, such as establishing how to maintain operational and economical feasibility as they ride out this momentum shift over the next few years.

“There is a necessary and natural time progression between when you start investing into population health — and the continuum of care — and when you start seeing benefits in terms of overall health of the population, as well as to the bottom line,” Luke says. “If this works correctly, you are going to start seeing volume decrease in the inpatient setting as you successfully keep the population healthier.”


A St. Joseph’s Home Care patient can benefit from a spectrum of services: skilled nursing, physical therapy, registered dieticians and social work.

As this momentum shifts, resources are allocated to community programs and the sustainability of the health system increases greatly, Luke adds. This allows St. Joseph’s Health to serve a greater population than in the past. St. Joseph’s Health partners with local providers to accomplish this, offering them participation in its Clinically Integrated Network (CIN). The CIN provides the framework for the continuum, controls costs, and ensures higher quality of care with partnered primary care and subspecialty physicians, as well as the opportunity for practices to collaborate with commercial payor organizations.

“The partnership between hospital administration and physicians is paramount to the success of the CIN,” says Paul Fiacco, MD, a family medicine doctor in East Syracuse who is affiliated with St. Joseph’s Health and the physician leader and medical director of the St. Joseph’s Health ACO/CIN. “It is incumbent upon both groups to be more accountable for the delivery of higher quality and more efficient care delivered at a lower cost. Physicians drive the overall care management of the patient as they navigate through the continuum while administration focuses on streamlining operations that are threatened by thinning margins due to an increased cost structure and reimbursement declines as we move away from the fee-for-service environment. Clinical integration helps improve quality, enhance the patient experience, reduce cost and waste in the system, and positions providers to take on higher levels of accountability to effectively manage utilization and the health of populations in the future. By working together and putting patient needs at the center of our continuum, we will enhance care, decrease cost and demonstrate considerable value to the consumer.”

The St. Joseph’s Health shift from pay-for-service to the continuum of care model, Luke says, allows the entire system to collectively improve and maintain efficiency, insurance incentives and financial viability over time.


(l-r front) AnneMarie Walker-Czyz, Senior Vice President for Operations and COO/CNO, Leslie Paul Luke, President and CEO, and Paul Fiacco, MD, Medical Director, St. Joseph’s Health ACO/CIN; (back) Mark Murphy, Senior Vice President for System Development and Ambulatory Care Administration

Paul Fiacco, MD, Medical Director, St. Joseph’s Health ACO/CIN, and Mark Murphy, Senior Vice President for System Development and Ambulatory Care Administration, St. Joseph’s Health

St. Joseph’s Health also increased its access to capital, resources, knowledge, best practices in population health and scope of services by partnering with Trinity Health in 2015 to further supplement the continuum framework that was already set in motion. This move also channeled more dollars into the organizations’ mutually shared Franciscan philosophy, placing increased emphasis on their mission to care for the needs of underserved populations, Luke says.

“As caregivers, all of us go into this business to take care of people and help them to be well or become well,” Luke says. “The shift to a population health model mirrors the core of our very purpose of existence. To achieve that mission while maintaining operational and financial viability is a win-win for everyone.”


For more information, visit sjhsyr.org.