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Population Health Management: Where are YOU?

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This presentation explains how population health is fundamental to value-based delivery models, including key principles and definitions of PHM, as well as how to assess your organization’s …

This presentation explains how population health is fundamental to value-based delivery models, including key principles and definitions of PHM, as well as how to assess your organization’s “population health readiness.”

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  • 1. Population Health Management Webinar: Where are You?…And How to Get Where You are Going Karen Handmaker, MPP, VP Population Health Strategies December 17, 2013
  • 2. About the Presenter Karen Handmaker, MPP VP, Population Health Strategies Phytel 2
  • 3. Learning Objectives 1. Assess your “population health readiness” 2. Understand your organization’s role in “value-based” models 3. Recognize that population health management is a technology-enabled team sport 3
  • 4. Are You Looking Below the Waterline? Do you only focus on the top 3%? >2/3 of catastrophic patients this year were not catastrophic the previous year You must focus on everyone below the waterline this year to prevent next year’s catastrophic cases. 5 Source: Healthcare Risk Adjustment and Predictive Modeling, Ian Duncan
  • 5. The “Triple Aim” is Driving Change 6
  • 6. Move from Volume to Value is Underway 7
  • 7. Patient-Centered Medical Home Model Has Traction • Primary care is the “front line” for population health • PCMH initiatives are achieving better health, better care, and lower costs • PCMH initiatives are reaching the tipping point with broad public and private sector support • PCMH initiatives offer both shortterm and long-term cost savings 8
  • 8. Organizations on Pathways to Population Health Physician integration Initial planning Clinical integration, PCMH, infrastructure, exploring population health Exploring Physician integration/ alignment, learning population health/ACO Design and  piloting Build ACO, expand risk contracts, continuous improvement in integration/alignment Active Rollout 9
  • 9. Are You Ready? Care delivery and management - Chronic care - Continuity of are - Non-traditional care Align and engage physicians - Continuum of care - Physician leadership - Risk and financial arrangements IT and informatics - Electronic health records - Analytics and decision support - Patient-centric technology Organization and environment - Structure / Governance - Strategic plan - Workforce Patient engagement and activation - Engagement / Activation - Behavior change - Self-care / Management Health promotion - Prevention - Screening - Educational Programs 10
  • 10. Shifting Expectations for “Provider Performance” Fee for Service PCMH Accountable Care 11
  • 11. We Are Still in Transition… Current View 30 Patients Per Day 14 have Chronic Conditions Unknown Health Risks Visits Too Short for Coaching Volume‐Based/Episodic New Population View 2500 Patient Population 900 have Chronic Conditions 1100-1250 have Mod-High Health Risk Care Teams Leveraged by HIT Value‐Based/Continuous 12
  • 12. Population Readiness Framework Achieving Top Level Goals… Strategic  Drivers Financial  Incentives • CIN Formation • ACO/MSSP • PCMH  Recognition • Employer  Contracting • Myriad Value‐ Based Contracts • Quality  Targets/P4P • Shared Savings • MU Stage 2 …Requires Bottom Up Approach Enterprise  Level PHM  Infrastructure Practice Level  PHM Best  Practices • EMR • Data Analytics  and Reporting • Patient Portal  • Care  Coordination  • Quality Culture  • Top of License  Care Teams • Total Population  Workflows • Actionable  Information 13
  • 13. PHM is a “Work in Progress” Major Goals… Strategic  Drivers …But Emerging PHM Financial  Incentives PHM  Infrastructure Best  Practices PCMH Recognition Payer P4P Common EMR but  Use Varies Workflows Largely  Manual  MSSP Award MSSP Shared  Savings CMs Employed  and Payer‐ Subsidized Actionable Data  Minimal Integration of PCP  Acquisitions MU Stage 2 Patient Portal and  HIE Coming Soon Care Teams Not at  “Top of License” Medical  Neighborhood  Loosely  Coordinated Focused on “Tip of  the Iceberg” Direct Employer  Contracting 14
  • 14. This is HARD: No Quality, No Shared Savings • Pioneer ACOs met quality reporting in 2012, but expressed concern about meeting performance benchmarks for 2013 • 9 Pioneers switched to MSSP or dropped out after Year 1 15
  • 15. “It Takes A Medical Neighborhood” Achieving Care Coordination Measures 16
  • 16. REQUIRED: Structured Data, Sophisticated Algorithms, Real Time Reports and Behavior Change 17
  • 17. Are You Leaving $$$ on the Table?? To meet your quality goals, can you identify, reach and assist all patients who need: • • • • • A visit? A test? Care coordination? Self-management support? Behavior change? 18
  • 18. New PCPCC Report: Health IT is “Must Have” for Population Management TEN RECOMMENDED HEALTH IT TOOLS TO ACHIEVE PHM: 1. Electronic Health Records 2. Patient Registries 3. Health Information Exchange 4. Risk Stratification 5. Automated Outreach 6. Referral Tracking 7. Patient Portals 8. Telehealth / Telemedicine 9. Remote Patient Monitoring 10. Advanced Population Analytics 19
  • 19. “Bottom Up” Quality Model QI Patient  Engagement Enabled Care Teams Data Integrity 20
  • 20. Job 1: Data Integrity • • • • Provider attribution Consistent and complete data capture Creating structured fields for quality measures Design-in continuous data quality management 21
  • 21. Is This a Process? “At registration, the front desk should confirm the PCP for every patient.” 22
  • 22. Provider Attribution Drives Valid Reporting Apply algorithms based on visit data to improve provider attribution accuracy Patients with Activity Last 24 Mos. Patients with Activity Last 24 Mos. Patients assigned  to invalid PCPs 25% Patients assigned  to valid PCPs 75% Patients assigned  to valid PCPs 97% Patients  assigned to  invalid PCPs 3% 23
  • 23. Sample Strategies to Improve Quality Measures 1. Existing Data Capture Use consistent locations in EMR for structured and scanned data (e.g., lab results, test orders, patient-reported data) 2. New Data Capture Create new structured fields rather than additional flow sheets for specific measures (e.g., fall risk assessment, Rx in care plan) 3. Eliminate Free Text Direct teams to use structured fields to collect data formerly entered as free text (e.g., tobacco cessation counseling, follow-up for positive depression screening) 4. Make Data Clean-Up Part of Standard Work Assign staff to regularly review provider attribution, invalid data entries, proper use of new workflows, etc. to enhance reliability 24
  • 24. Enabling High-Performance Care Teams • • • • Start with population view Stratify patient population by risk and needs Assign care team members to defined cohorts Create lean workflows with HIT to drive high performance 25
  • 25. Stratify Population for “Top of License” Workflows 40-50% 26
  • 26. Align Patient-Centered Care, PCMH and TQM Source: Value-Based Health Care Delivery: Integrated Practice Units, Outcome and Cost Measurement, Professor Michael E. Porter, Harvard Business School, DHCS Health Care Seminar, June 4, 2010 27
  • 27. Practice Innovations that Produce “Joy” Source: In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices, Ann Fam Med 2013;11:272-278. doi:10.1370/afm.1531. 28
  • 28. Optimize Care Team Roles with Automation Patient Service Representative or Medical Assistant •Schedule visits and tests indicated in care gap and Pre-Visit reports •Send out pre-visit communications and conduct follow up using automated Campaigns Care Manager Physician •Stratify patients by risk using Coordinate reports and filters •Review Patient-Centric Registry reports for attributed patients •Use Campaign functions to reach out to subgroups of patients with care gaps •Assign high risk patients to Care Manager using reports and filters •Reinforce importance of proper diabetes management through personal and automated patient education •Address all diabetes care opportunities at every encounter, even for nondiabetes visits, using realtime patient data CMO/Quality Committee •Review performance on each clinical goal overall and by location and provider •Meet with MDs and Care Teams at least monthly to review progress 29
  • 29. Create Workflows with HIT Assists 1) All >9 A1c and no office visit are sent a text message to call care manager 2) All >9 and BMI >35 are sent an automated invitation to a group visit with a diabetes dietician 3) All between A1c 7 and 9 are sent an automated message to encourage visit website to take diabetes selfmanagement course 4) All diabetics <7.0 are sent an email message emphasizing the importance of nutrition and exercise to maintain low A1c levels with a link to a mobile app to track their progress 30
  • 30. Patient Engagement • • • • Know your patients as people, not care gaps Incorporate behavior change principles into all encounters Use HIT to engage all patients, not just those who present Be proactive and persistent 31
  • 31. We WANT/NEED Him to Go Towards "Better Health" Our agenda for Oscar: • Medication adherence • Come to follow-up appointments • Improved self-monitoring • Participation in PT • Nutritious food choices and increased calories • Living Will • Participate in Shared DecisionMaking 32
  • 32. Tying Strategies to Engagement 33
  • 33. Engage All Patients in Multiple Ways 34
  • 34. An Outreach Strategy is a Must A strategy for identifying patients lost to planned follow-up is critical to population health management 35 35
  • 35. Quality Improvement • • • • Depend on real time data Make data available at all levels of the practice Always look below the waterline Share results regularly 36
  • 36. How Are These Providers Doing? 37
  • 37. % of Patients with 9+ HbA1c  Result Uncontrolled Percentage Increasing 14.0% 12.0% 10.0% 10.5% 8.8% 9.3% 8.0% 6.0% 4.0% 2.0% 0.0% Year 1 (2009‐2010) Year 2 (2010‐2011) Year 3 (2011‐2012) “How can this be if I am managing all of our patients with A1c results >9?” 38
  • 38. Where Were 9+ HbA1C Patients Last Year? 39
  • 39. Track Performance to Target Improvement • Monitor performance measures • Compare provider and care team results • Use drill-down capabilities to find outliers and take action 40
  • 40. Automated Population Health Model 41
  • 41. Take Home Messages The move from volume to value is underway • And most of you are on this path Take a system approach and a population health view • Value-based payment changes everything Population health management is a team sport • • Across providers and sites of care Between providers and patients Build in HIT “assists” to enable and achieve PHM • • • • Configure to the measures Facilitate care coordination workflows Automate patient engagement and monitoring Put real-time data in the hands of the front line 42
  • 42. Questions? Karen Handmaker VP Population Health Strategies, Phytel Karen.handmaker@phytel.com 43