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Session 11B - Increasing MTF Effectiveness & Efficiency

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Session 11B - Increasing MTF Effectiveness & Efficiency

  1. 1. Session 11b: Linking PopulationHealth and MedicalManagement CDR James Ellzy, MD, CMQ Teaching Faculty, DeWitt Army Family Medicine Residency & Immediate Past Director of MHS Clinical Quality james.ellzy@amedd.army.mil 11-1
  2. 2. Outline • MTF Utilization of Population Health • MTF Utilization of Medical Management • TMA Resources 11-2
  3. 3. 11-311b - 3
  4. 4. Population Health - Outcomes Where we were... Where we are moving… FOCUS ON DISEASE FOCUS ON HEALTH • Sub optimal satisfaction • Enrollment • Increase appropriate access • Appointment system • Improve population health • Claims processing • Enroll and assess needs • Sub optimal points of access • Primary disease/injury prevention • Advice/Triage/E.R. • Clinical practice guidelines • Highly episodic utilization • Demand management • Many unplanned visits • Referral management • Lack of continuity • Case management • Decreased “health status” • Ensure continuity of care • Increased satisfaction & loyalty INTERVENTION PREVENTION 11-4
  5. 5. Why do we care? • Because leadership is tracking it… • Gaps exist in quality of care… • Persons with disease/risk cost more… • We work in a financially constrained environment • Improves outcomes, productivity, satisfaction 11-5
  6. 6. 11-6
  7. 7. Population Identificationand Assessment Identification Assessment Data resources• Who are… • What is the health • Medical record reviews • The eligible status? • Health risk assessment beneficiaries? • What are the lifestyle • Health related behavior• Who is… risk factors (behaviors)? survey • Enrolled to the MTF? • Who needs clinical • MHS Population Health• Who is… preventive services? Portal • Enrolled to your • What is the prevalence clinic? of chronic disease?• Who is… • Who are the high SCENARIO: utilizers of services? Who is the • Being seen in your clinic? population at each of your three MTFs? 11-7
  8. 8. 11-8
  9. 9. Demand Forecasting • Requires: • Accurate population identification (size, gender, age) • Knowledge of: • Health care needs of the population (imms & other CPS) • Prevalence of disease/conditions within the population • Clinical practice guidelines (including VA/DoD CPGs) • Operationally defined & system-required demands (pre- deployment requirements, physical exams, overseas screening, etc.) • Resources: • Utilization Reviews (historical data such as chart reviews and M2 queries) • Demand Forecasting models 11-9
  10. 10. 11-10
  11. 11. Demand Management• A collection of proactive interventions focused on reducing unnecessary health care utilization while encouraging the appropriate use of health care resources.• Strategies: • Increasing SELF-CARE Strategies & Patient Education • PCM Assignments (Right patient mix & distribution) • Nurse Triage • Message Center SCENARIO: • Making the most of every visit How could • Immunizations at acute visits Colonel Smith’s • Oral prophylaxis at dental exam appointment utilization have • Medication refills at every visit been better • Optimizing ALL team members managed? 11-11
  12. 12. 11-12
  13. 13. Capacity ManagementMatching the quantity and quality of healthcare services • Provider availability provided at the MTF with the • Provider type needed needs of the population. • Support staff • Ancillary supportFactors affecting capacity requirements Management: • Readiness requirements• Patient demand • Physical space• Appointment types • Equipment needs • Open Access • Group Appointments SCENARIO: Any pertinent issues discussed yesterday afternoon? 11-13
  14. 14. 11-14
  15. 15. Evidence-Based Careand Prevention• The provision of healthcare using a systematically developed, research-based approach • Identifies people with or at risk for chronic disease• Provides patients & families: • Evidence-based information & tools (e.g. CPGs) • Multidisciplinary team to follow plan of care • Referral to resources, as needed (e.g., case management, disease management) • Health promotion and/or patient self-management education 11-15
  16. 16. Evidence-BasedHealthcare Goals• Improved Quality of Life SCENARIO: What 3 chronic • Higher Functional Status diseases of Col • Self-Management Smith do we have VA/DoD CPGs? • Fewer Hospitalizations/Acute Visits• Improved Quality of Care • Reduced variation• Decreased Costs  More Resources Available for Prevention Strategies 11-16
  17. 17. 11-17
  18. 18. Program Evaluation & Feedback • Implementing Clinical Practice Guideline (CPG) is NOT enough • Measure outcomes to evaluate your program’s processes and performance • Service required clinical metrics • Use the Population Health Portal on CarePoint • National benchmarks (examples) • Healthcare Effectiveness Data and Information Set (HEDIS®) • Healthy People 2020 • Joint Commission-ORYX 11-18
  19. 19. Medical Management Model 11-19
  20. 20. Case Management (CM)• Definition: • A collaborative process under the Population Health continuum that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes. • DoD Medical Management Guide 2009 11-20
  21. 21. Case Management (CM)• Goals: • Promote quality, safe, and cost-effective care. • Promote utilization of available resources to achieve clinical and financial outcomes. • Facilitate appropriate access to care. • Collaborate with the patient/family, physician, healthcare providers, and others to develop and implement a plan that meets the needs and goals of the patient. • Develop individualized patient plans of care. • Offer objectivity, healthcare choices, and self-management solutions. SCENARIO: • DoD Medical Management Guide 2009 How could Col Smith have benefitted from Case Management? 11-21
  22. 22. Case Management (CM)The MHS has three primary goals for CM:• Improve the care, management, and transition of recovering Service members.• Broaden the application of CM to include beneficiaries with complex needs and at-risk beneficiaries before they require complex care.• Evaluate the impact of CM on the quality and efficiency of military health care.Additional goals applicable to caring for wounded warriors are to:• Assist the recovering Service member in receiving quality medical and behavioral health (BH), which may include lengthy inpatient stays and transistions between facilities or between outpatient medical and BH services.• Assist the recovering Service member and his/ her family in understanding the recommended treatment (including BH services) and in receiving timely access to that treatment. 11-22
  23. 23. Utilization Management (UM)• Definition: • An organization-wide, interdisciplinary approach to balancing cost, quality, and risk concerns in the provision of patient care. UM is an expansion of traditional Utilization Review (UR) activities to encompass the management of all available healthcare resources, including Referral Management (RM). -DoD Medical Management Guide 2009 11-23
  24. 24. Utilization Management (UM)• Goals: • Maintain the quality and efficiency of healthcare delivery by: • Providing patients with the appropriate level of care. • Coordinating healthcare benefits. • Promoting the least costly, most effective treatment benefit. • Determining the presence of medical necessity -DoD Medical Management Guide 2009 SCENARIO: How could Col Smith have benefitted from a working Utilization Management Program in this Multi-Service Market? 11-24
  25. 25. Disease Management (DM)• Definition: • An organized effort to achieve desired health outcomes in populations with prevalent, often chronic diseases for which care practices may be subject to considerable variation. DM programs use evidence-based interventions to direct patient care. DM programs also equip the patient with information and a self-care plan to manage his/her own health and prevent complications that may result from poor control of the disease process. The term “condition management” includes non-disease states (e.g., pregnancy). -DoD Medical Management Guide 2009 11-25
  26. 26. Disease Management (DM)• Goals: • Improve clinical outcomes • Increase patient and provider satisfaction, • Promote appropriate utilization of resources throughout the MHS• Purpose: • Improve the quality of life for individuals by preventing or minimizing the impact of a disease or chronic condition. -DoD Medical Management Guide 2009 SCENARIO: What diseases of Col Smith’s should be part of a Disease Management program? 11-26
  27. 27. Medical ManagementGuidance • Department of Defense Instruction (DoDI) 6025.20 (dated Jan 2006) • Population Health/Medical Management Guides • Available: www.tricare.mil/OCMO/publications.aspx • Medical Management Webinars available. Schedule at www.tricare.mil/tma/ocmo/webinars.aspx 11-27
  28. 28. Milliman Inpatient& Outpatient Guidelines• Enterprise-wide license for evidence based guidelines that supports outpatient and inpatient care (replaced McKesson’s Interqual on the inpatient side). • Clinical judgment still needs to be used • As a commercial product, it doesn’t always match up with the TRICARE benefit. TRICARE rules must be followed in their application and use!• Other details • Updated annually • Requires an account/password, • Free for MTF personnel use (paid by TMA) • Username: mhs • Password: referral • Access link via: http://careweb.careguidelines.com 11-28
  29. 29. Milliman Inpatient& Outpatient Guidelines Ambulatory Care: Imaging & Diagnostic Testing DME & Injectables Inpatient and Surgical Care: Referrals & Rehab Services Actionable Criteria Detailed Care Pathways General Recovery Guidelines: Observation care guidelines Expanded decision support Integrated Quality Measures Long-term acute care Easy evidence access Evidence-based complex Patient Information Package treatments Problem oriented guidelines Behavioral Health Guidelines: End-of-life guidance Clinical indications & alternatives for admission Recovery Facility Care: Detailed discharge criteria Clinical indications Partial hospital care planning Problem-oriented guidelines Flexible recovery courses Detailed treatment plans Alternative care planning Multiple length of stay measures Care management tools 11-29
  30. 30. Military Health System Toolsand Resources• MHS Population Health Portal (MHSPHP) on CarePoint • Highlights importance of accurate documentation and coding = improving data quality https://carepoint.afms.mil• VA/DoD CPGs & toolkits: • www.qmo.amedd.army.mil 11-30
  31. 31. Questions? 11-31

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