HIMSS GC3_It Takes A Village (Nov 4, 2016)
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Population health management programs are evolving from transactional and fragmented approaches focused on discrete conditions to more advanced, integrated models led by physicians and aligned with providers. Successful programs require six core capabilities: data aggregation, segmentation and analysis, care coordination tools, strategic and financial analysis, patient engagement, and workflow integration. Programs must also implement tailored strategies and interventions based on risk stratifying distinct patient populations.
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HIMSS GC3_It Takes A Village (Nov 4, 2016)
- 2. Agenda • What’s Driving the need for Population Health? • Evolution of Population Health Programs • Framework and Foundation • Other Key Factors • Results • Summary
- 4. Challenges: Unprecedented Factors in Play Increasing shortage of healthcare providers Providers will adopt ‘Virtual Care’ to increase capacity By 2030, 20% of Americans will be over the age of 65 100M patients trying to maintain or regain a healthy lifestyle 170M have at least one chronic disease Patients in need of family & social support ‘Network’ Exponential growth in cost, with declining reimbursement Patients will share the ‘Risk’ = Cost of care Challenges: Unprecedented Factors in Play
- 6. What is Population Health Management? Population Health Management is a systematic approach to optimizing the health of populations and preventing people from getting sick or sicker Population Health Management uses data and technology to drive better health outcomes for patients by giving providers the ability to monitor their entire patient population at-a-glance and in real-time
- 8. Technology: A Key Driver in this Transformation Quality • PPACA • Meaningful Use • Payer provider convergence • Self‐monitored healthcare • Physician engagement • Virtual healthcare delivery • HIE • Clinical integration • Electronic Medical / Health Records (EHR/EMR) • Care financing • Care management applications • Physician management solutions • Telehealth • Practice management solutions • Cloud • Mobility • Data analytics • Cloud • Big data analytics • Mobility & Social media • Internet of Things (IoT) • Mobility & Social media • Big data analytics • Internet of Things (IoT) Stakeholder Initiative Healthcare Tenet(s) Technology Tenet(s)
- 9. Population Health Management Redefined Population Heath Management is a comprehensive set of activities focused on a defined population that improves quality and outcomes, while lowering per capita cost of care and is incentivized through contracts that accept financial risk and/or reward. Value Quality + Patient Experience + Outcomes Cost
- 11. Population Health Management Programs are Maturing • Transactional focus • Fragmented and siloed • Focused on discrete conditions and events • Seen as restrictive and reactive Traditional (Payer Based) • Member centric • Condition based • Focus on trend mgmt. • Increased focus on: ‐ Wellness ‐ Gaps in care ‐ Provider coordination Advanced (Payer+ Based) • Physician led ‐ Accountable care models ‐ Bundled payments ‐ CPC+ ‐ DSRIP ‐ MACRA (MIPS & APM) • Aligned incentives • Integrated at point of care • Value‐add services • Robust informatics Aligned (Provider Based) Alignment and Accountability Engagement and Collaboration
- 13. Staged IT Investments by Providers under Risk Based Contracting Source: Health Care Advisory Board
- 15. Six Key Capabilities needed to Successfully Manage Population Health ‐ KLAS The 6 core tenets, which KLAS calls “verticals” 1. Aggregation of disparate clinical and administrative data to support population health. 2. Segmentation and analysis of aggregated data to communicate meaningful information. 3. Care coordination and health improvement tool to support standardized intervention. 4. Internal/external analysis of administrative and financial strategic programs. 5. Patient engagement aligned with goals for improvement. 6. Actionable workflow integration to improve clinician engagement. • http://www.healthdatamanagement.com/news/stakeholders‐identify‐key‐tools‐functionality‐for‐pop‐health?reading_list=%5B%2700000157‐bda4‐d031‐a57f‐ fde4a66c0000%27%2C%2700000157‐ba5d‐d031‐a57f‐fbfd5b410000%27%2C%2700000157‐ba58‐d274‐a3df‐bad9e59b0000%27%2C%2700000157‐bdb0‐d274‐a3df‐ bdf9b2a50000%27%2C%2700000157‐b890‐d274‐a3df‐b8d93fcc0000%27%2C%2700000157‐bdbd‐d031‐a57f‐fdfd65650000%27%2C%2700000157‐ba4f‐d031‐a57f‐fbeffa7d0000%27%5D
- 16. Population Health Management Framework Technology Foundation • Strategy • Scope of Services • Payer Relationship • Quality Paradigm • Community Alignment • Financial Strategy • Bundled Payment • Risk Based Contracting • Cost Accounting • Financial Analytics •Health Profiling •Risk Stratification •Care Planning •Next Generation Care Delivery •Outcome Management •Outreach •Education •Care Coordination •Collaboration •Tracking & Monitoring •Care Alignment Business Model Financial Model Engagement Model Care Delivery Model Triple Aim Better Care
- 17. Population Health Management ‐ Maturity Matrix Phase 5 TRANSFORMED Phase 4 OPTIMIZING Phase 3 ENHANCING Phase 2 FOUNDATIONAL Phase 1 CONCEPTUAL Business Model • Strategy in action • Cradle to grave services • Integrated self‐directed payer w/ >90% contracts at risk • Quality measures adopted as standard • Official dept. for community engagement • Strategy funded • Affiliated network provides full suite of services • >75% contracts at risk • Non‐regulatory quality standards adopted • Individual responsible to include payers • Strategy approved • External contracts provides suite of services • >50% contracts at risk • Payer quality measures adopted • Individual responsible to exclude payers • Strategy documented • Acute, specialty and primary care • Quality metrics tracked • Individual responsible for community members • No Strategy • Basic acute care services • External quality measures for reporting purposes only • Plan complies JCAHO Financial Model • ELT, finance & clinical alignment • CMS and commercial bundled pmt. contracts • Full ACO strategy with risk sharing contracts managed • Predictive reporting for cost accounting at patient level • Reports driving costs out and improve quality • ELT and clinical alignment • CMS bundled pmt. contracts only • ACO strategy and risk sharing contracts in place • Real time analytics for cost accounting at population • Cost and care metrics • ELT and finance alignment • Few bundled pmt. contracts • Risk sharing contracts but no ACO strategy • Retroactive cost for population level • Care metrics reporting only • No cross disciplinary involvement • No bundled pmt. • No risk sharing contracts • Departmental level costs • No analytic for cost/quality • No financial strategy • No plan for bundled pmt. • No plan for risk sharing • Organizational level costs • No analytics capability Care Delivery Model • All health data including biometric and genetic • Risk based on clinical, non‐clinical, claims, social etc. • Evidence based longitudinal care plans for all patient type • Mobile monitoring, wellness coaching and virtual care • Culture of perf. improvement for pt. experience & outcomes • Clinical, socio‐economic, environmental & daily activity • Risk based on claims, clinical and non‐clinical data • Low risk patients educated • Home monitoring and virtual visits for complex care • Data transparency & coaching • Clinical, socio‐economic and environmental data • Risk levels based on claims • Rising risk patients proactively managed • Telehealth use in acute care • Targets for care pathways • Adds data collected via HRA • Risk levels based on HRA’s • Chronic disease mgmt. pathways • Limited telehealth use • Outcome & utilization tools • Health data limited to EHR • Minimal risk stratification • Reactive and episodic • Not using telehealth • No outcome & utilization tools Engagement Model • Customized outreach based on customer preferences • Personalized education when, and where needed by patient • Pt. can access support services via digital channels • Ongoing secure dialogue via several channels of comm. • Collaborative goal setting w/ coaching to support progress • Personalized staged outreach • Staged education with teach back and patient surveys • Coordinates and tracks use of community support services • Family & caregivers included • Tracked and monitored goals shared w/ broader care team • Targeted outreach • Education accompanied by teach back method • Coordinates support services • Regular comm. w/ care team • Trackable actionable goals • Pt. managed outreach via email, portal, mail and phone • Online info. accessible by pt. • Connects support services • Comm. via portal and phone • Actionable goals post visit • Pt. outreach via mail & phone • Paper based education • Provides community resource • Episodic comm. via phone • Recommendation post visit Technology Foundation • Distinct PHM funding & resources • PHM tech can automatically modify patient care plans • IT governance has separate steering group for PHM • Strategy and FHIR capabilities in place w/ integration from disparate sources • PHM project dedicated resource • PHM can provide utilization information for financial & clinical • FHIR being investigated but no defined integration strategy • PHM project contracted resource • PHM technology partially implemented & future defined • Robust IT governance but PHM not highlighted • PHM projects funded separately • Specific PHM tech. planned • Integration tools exist using HL7, but no strategy in place • PHM projects integrated w/ IT • No specific PHM technology • IT governance is not robust • Project based P2P integration Phase 5 TRANSFORMED Phase 4 OPTIMIZING Phase 3 ENHANCING Phase 2 FOUNDATIONAL Phase 1 CONCEPTUAL
- 19. 8 Steps to Enable Population Health Management Design/refine the business and financial model Identify and present care gaps as actionable insights via an easily interpreted dashboard 1 Design/refine the business and financial model Define 2 Aggregate and normalize claims, clinical, HIE, registry and socio-economic data Aggregate 3 Stratify data to prioritize list of high risk and rising risk population Stratify 4 Identify and present care gaps as actionable insights via an easily interpreted dashboard Identify 5 Create a personalized care plan for the patients identified Plan8 Measure and track against the expected clinical and programmatic results Measure 6 Engage with patients, families, communities and clinicians to manage health conditions Engage7 Coordinate with care teams for different segments to improve outcomes Manage Improve Health | Lower Costs | Quality Care
- 21. Prioritize Investments by Patient Population 1). Investments may be for partnerships, rather than acquisition or brick-and-mortar 2). Investments here may be for retraining existing staff, rather than hiring new staff. Source: Health Care Advisory Board Interviews & Analysis
- 22. Care Management: Services across the Entire Lifecycle of Patient’s Healthcare Delivery Needs Care Management Care Intervention Diagnostics Treatment Wellness Management Medical Adherence Management Monitoring & Tracking Patient Profiling Comprises a collection of people, processes and technology to improve population health collaboratively Comprises of post- intervention activities to maintain health Comprises of onsite or remote care delivery based on analysis for right diagnostics and medical treatment Applications that diagnose illness or help with early detection by analyzing lab results and patient records Applications that identify right treatment (drug, provider or cost) methods based on big data analysis Applications that track medicine intake after onsite or remote care intervention Applications that track body’s real- time vitals through IoT applications Applications that profile patients based on food habits, exercise regime and medication to send customized alerts via mobile devices Source: Everest Group
- 23. Linear View of Care Management Applications Tele-psychiatry Medication mgmt. Tele-stroke Chronic care mgmt. Virtual urgent care Retail care Wearables Mobile apps Virtual primary care Patient portals Online support groups Clinician to Clinician Provider to Patient Consumer Driven Tele-dermatology 2nd opinion School health Prescription refill Wellness, disease mgmt. Tele pharmacy Tele-radiology Tele-cardiology eNICU Tele-retinal image Tele-pathology Tele-audiology eICU 2nd opinion Tele-surgery Tele-trauma eVisits Geo-tagged devices
- 25. Checklist for PHM Partnerships 1. Commit early on to develop the competencies and infrastructure required to advance population health. 2. Acknowledge that owning or operating every component of the care continuum is probably not possible for most organizations. Partnerships will be a valuable asset, especially those with post‐acute offerings. 3. Have clear goals for partnership arrangements and specify how success will be defined and measured. 4. Define the partnership network delivery elements and responsibilities. 5. Determine which party is responsible for functions such as population health analytics and utilization management. 6. Consider arrangements that will allow your organization to manage population health without assuming full financial risk for an insurance product. 7. Evaluate various product offerings that are available through partnerships with insurers. 8. Determine the level of provider risk your organization desires to carry. 9. Identify the means of economic integration the partnership will offer, as well as the expected revenue model. 10. Identify the assets your organization will contribute to or invest in the partnership. 11. Determine the terms for ending the partnership. Source: Kauffman Hall
- 26. Comparing Vendor Partners to Your Needs Score Priority Score Priority Data security Custom reporting Data silos Standard reports Data acquisition timing Custom stability Data reporting timing Client list / Experience Data exportable Base cost Data normalization Care coordination program Big data platform Alerts / Reminders Scalability Best practices ‐ Value driven Integration to HIE / platform Risk assessment Proven connectivity Provider attribution API‐Driven Interface Patient registration / identification Cloud multi‐tenant Total cost of care
- 30. Provider‐Payer Collaboration is Key Provider‐payer relationships are evolving in the era of payment reform and value‐based care. The “us vs. them” mindset needs to evolve into a collaboration built on trust and respect. Payers and providers must continue to successfully align their goals in order for both to succeed and patients to benefit Principles of Sustainability 1. Attribution – linking people to their PCP 2. Define episodes – whole person vs. disease 3. Transparency – data and variation 4. Metrics that matter 5. Aligned incentives
- 32. Results
- 33. Typical Population Health Care Delivery Challenges Limited Risk Analytic Capability Dated Technology No Cost or Care Metrics Disengaged Family & Caregivers Limited Population Insights Inability to Contract Risk Lack of Strategy Misaligned Network & Leadership
- 36. Summary