Improving the Health Outcomes of Both Patients AND Populations
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NCA Clinical Workforce Development, Team-Based Care 2019 Webinar Series Webinar broadcast on: May 23, 2019 | 2 p.m. EST In this webinar experts will share their journey in planning, preparing and launching a population health initiative. With the goals of impacting population health outcomes while ensuring cost effectiveness, our experts designed interventions to eliminate gaps in care, particularly among special populations.
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Improving the Health Outcomes of Both Patients AND Populations
- 1. Improving the Health Outcomes of Both Patients AND Populations May 23rd, 2019
- 2. Expert Panelists Margaret Flinter APRN, PhD, FAAN • Senior Vice President/Clinical Director & Co-PI, NCA Tierney Giannotti, MPA • Senior Quality Improvement Manager of Population Health Mary Blankson, DNP, APRN, FNP-C • Chief Nursing Officer Bethany Buckridge, BSN, RN • Population Health Nurse Robert Block, CPA • CHCI Chief Financial Officer
- 3. Do you have an employee with population health in their title? • Yes • No • Uncertain
- 4. Disclosure • With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship between the party listed above (or spouse/partner) and any for-profit company in the past 12 months which would be considered a conflict of interest. • The views expressed in this presentation are those of the presenters and may not reflect official policy of Community Health Center, Inc. and its Weitzman Institute. • We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under investigation (not FDA approved) and any limitations on the information hat we present, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion.
- 5. Get the Most Out of Your Zoom Experience • Use the Q&A Button to submit questions! • Live tweet us at @CHCworkforceNCA • Recording and slides are available after the presentation on our website within one week • View past webinars at www.chc1.com/nca
- 6. CHC Profile: Founding year: 1972 Over 200 service sites Patients/year: 100,000 6
- 7. The Weitzman Institute works to improve primary care and its delivery to medically underserved and special populations through research, innovation, and the education and training of health professionals. Weitzman Institute 7
- 8. Provides education, information, and training to interested health centers on: Transforming Teams • National Webinars on the team based care model • Invited participation in Learning Collaboratives to launch team based care at your health center Training the Next Generation • National Webinar series on developing nurse practitioner and clinical psychology residency programs and successfully hosting health profession students in health centers • Invited participation in Learning Collaborative to implement these programs at health center National Cooperative Agreement Clinical Workforce Development
- 9. Learning Objectives 1. Define population health 2. Assess your health center’s progress in implementing key components of population health 3. Identify strategies to integrate initiatives focused on population health 4. Examine an approach to estimating the financial return on investment for population health
- 10. • Kindig and Stoddart’s definition from 2003 was “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” • Definition evolved with the recognition of the need to incorporate the role of healthcare providers in impacting those outcomes. • Since then, various entities, (e.g., CDC, RWJF), have adopted a more interdisciplinary approach, that highlights the importance of non- traditional partnerships among different sectors in achieving positive health outcomes. • Focuses on populations “within specific geopolitical area” and goes beyond their clinical health to include “social, economic, environmental, and individual behavioral and genetic traits.” Defining Population Health Sources: 1. Kindig D, Stoddart G. What is population health? American Journal of Public Health 2003 Mar;93(3):380-3. 2. The National Association of Community Health Centers. “Population Health Management Factsheet.” (2015) Retrieved from; http://www.nachc.org/wp-content/uploads/2015/12/NACHC_pophealth_factsheet_FINAL.pdf
- 11. 1. Improve patient outcomes Goals of Population Health 2. Increase purposeful spending and reduce wasteful spending 3. Secure appropriate reimbursement from value based work
- 12. Framework Adaptation Adaptation of two population health frameworks: • National Association of Community Health Centers (NACHC), proposed eight “Action steps toward population health management”. • Partnership (RWFJ Funded) among American Hospital Association/Health Research & Educational Trust, Institute for Healthcare Improvement, Network for Regional Healthcare Improvement, Public Health Institute, and Stakeholder Health, to create “Pathways to Population Health: An Invitation to Health Care Change Agents”. The NACHC Population Health Management factsheet can be found at http://www.nachc.org/wp- content/uploads/2015/12/NACHC_pophealth_factsheet_FINAL.pdf Stout et al. Pathways to Population Health: An Invitation to Health Care Change Agents. 2018. Retrieved from http://pathways2pophealth.org/files/Pathways-to-Population-Health-Framework_102218.pdf
- 13. Framework Improve Health of the Population – Data – Team-Based Care – Behavioral Health Integration – Care Management Improve Social Well Being of the Population – SDOH Screening and Referrals – Health/Community System Partnerships and Communication Systems Issues to Consider – Redeploy staff – Financial Return on Investment
- 14. Organizing Patient Data • Consider all data sources • Assign patients to panels/Empanelment • Develop and use patient registries • Outreach to patients you may not have met Improve Health of the Population
- 15. Risk Identification • Risk scores generated from internal and/or external using different methodologies • May use patient’s prior history of ER visits, admissions and/or conditions, health outcomes, SDOH How do you decide who within the population to focus on? • Dashboards, leveraging the team, etc. Risk-Stratification Improve Health of the Population
- 16. Do you collect and/or use risk scores? • Yes • No • Uncertain
- 17. • Provide access to actionable data directed to the appropriate team members • Care gaps for patients here for a visit today • Hospital admissions and discharge lists • Consider method of dissemination • Within the EHR • On dashboards updated daily/monthly • Via Excel files Population-Specific Interventions Require the Use of Data Improve Health of the Population
- 18. Do you get notification when patients are admitted and/or discharged from the hospital? • Yes • No • Uncertain
- 20. Elements of Planning for a Population Health Approach • Centralized approach • Decentralized approach
- 21. • Increase pediatric behavioral health screening • Implement Medicare Annual Wellness Visits • Reduce unnecessary emergency room visits Population-Specific Interventions To: Improve Health of the Population
- 22. 22 How Behavioral Health Integration Supports Population Health Medical initiated warm hand-off and behavioral health initiated warm hand-off • Reactive: Initiated by medical provider (e.g. medical screenings) • Proactive: Initiated by BH provider based on dashboard • BH diagnosis and no BH visits • Health related diagnoses that can impact emotional health • e.g. opioid prescription, chronic pain diagnosis, nicotine use diagnosis) • High risk patient can be a client with a PHQ score over 15 (moderately severe)
- 24. How Telehealth Supports Population Health Improve Health of the Population Health centers have increasingly recognized the potential for telehealth, in its various forms, to address service and access gaps resulting from provider shortages • eConsults • Synchronous • Asynchronous
- 25. Nursing Visits/Co-Visit with BH (in- between provider visit surveillance) • Routine prescription monitoring programs (PMP) Checks (delegate status) • Medication Reconciliation • Side Effect Surveillance • Random/Routine Toxicology • Controlled Substance Agreement Review/Signing Nurse Care Management Supports Population Health Improve Health of the Population
- 26. How Ongoing Training and Education Supports Pop Health Complex Care Management, which is a telehealth model that creates a knowledge network for nurses Includes both didactic and case-based learning, where frontline nurses and student nurses can present complex cases and get feedback and support from a multi- disciplinary team of experts on next steps in their care planning Improve Health of the Population
- 27. Focusing on SDOH Screening and Referrals Supports Population Health Improve Social Well Being of Population Some SDOH to Consider: • Housing • Utilities • Access to Food • Safety Social determinants of health (SDOH) are conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. SDOH contribute to 40-50% of health outcomes. Sources: US Department of Health and Human Services. (2013). Healthy People 2020 topics and objectives. Washington, DC. Artiga, S., & Hinton, E. (2018). Beyond health care: the role of social determinants in promoting health and health equity. Health, 20, 10.
- 28. Engage with community based agencies • 211 • Food pantries • Community Action Teams • Community Collaboration Meetings (CCTs-Hospitals) • School-Based Health Centers Health/Community System Partnerships and Communication
- 29. Review the roles of existing staff: • Changes to job descriptions • Break up tasks among different roles when implementing new processes Redeploy Staff Systems Issues to Consider
- 30. In a study published in 20171, a risk-stratified primary care delivery model that used population health strategies and predictive modeling to match clinical resources to patient needs reduced inpatient and total spending, at a ratio of $4 saved for every $1 spent on the program. In the study period, payers saved $15.8 million (1.7% of risk adjusted expected cost) during a 26-month implementation period with a cost of $3.9 million. Financial ROI Sources: 1. Johnson T, Heijde M, et al. Population Health in Primary Care: Cost, Quality, and Experience Impact. The American Journal of Accountable Care 2017 Sept;5(3):10-20.
- 31. Additional Reimbursement Return on Investment (%) = ------------------------------------ - 1 Additional Annual Expense Financial ROI For example, annual cost of Population Health program is $500,000, and additional reimbursement is $700,000, then ROI is 40%: $700,000 ROI = ------------ - 1 = 1.4 – 1 = 40% $500,000
- 32. Financial ROI Additional Potential Reimbursement: 1. Monthly PMPM for attributed patients 2. Shared Savings payments 3. Quality Improvement payments (including HRSA) 4. Value Based Payments from Private Payors for Achieving Targets
- 33. Financial ROI Additional Expenses: o Salaries/Fringe of Enhanced Care Team o IT Hardware o IT Software o Risk stratification, clinical decision support o Annual IT Maintenance/Support o Salaries/Fringe of Evaluation personnel o HIMs, informaticists, data scientists, data analysts
- 34. Transitioning from Volume Based Payment to Value Based Payment
- 35. Questions
- 36. Visit our National Learning Library Contact us at nca@chc1.com www.chc1.com/nca
- 37. Resource Highlights National Learning Library www.chc1.com/nca February 15 | Taking Team-Based Care to the Next Level Video Slides February 22 | Advancing the Practice of RNs and Behavioral Health Providers Video Slides February 27| The Vital Role of Behavioral Health: Effective Integration in a Model of Team Based Care Slides
Editor's Notes
- Tierney--- Pop health was focused on health outcomes and measures– left out providers– easily interchangeable with public health Pop health and public health are related but not interchangeable Public health department now includes health care providers, private sector, multi-stakeholder approach Transition--- Tierney gives context to her story/work as the pop health manager
- Triple aim*** addition to this slide? Margaret rewording*** Investment (purposeful spending) Lead and drive the movement towards VBC fair payment and reimbursement for our efforts for vbc--- lead innovations---*** PCMH Plus content– % of patients into a value based payment arrangement
- Tierney Copy and paste the beautiful portion here*** In 2018 five partner organizations: American Hospital Association/Health Research & Educational Trust, Institute for Healthcare Improvement, Network for Regional Healthcare Improvement, PuPooled resources to create “Pathways to Population Health: An Invitation to Health Care Change Agents”. A framework to support health care professionals to make practical, meaningful, and sustainable advancements in improving the health and well-being of the patients and communities blic Health Institute, and Stakeholder Health. they serve. Pathways to Population Health is committed to providing a clearer and more coherent understanding of what it means for health care organizations to be on the journey toward population health. This collaboration is facilitated by 100 Million Healthier Lives, a movement of change agents working to transform the way we think and act to create health, well-being, and equity.
- Tierney Weave PCMH recognition throughout these themes
- Tierney Title revision– ‘Every patient belong to someone’ ‘Organizing the Data: The Who’ ‘Organizing Patients/Patient Data’ Empanelment punch on that content- every patient belong to some bodies** Share provider or share the condition or share the risk factor Not everyone calls them patient registries– not always notes in the literature--- other places population based dashboard– electronic tool– track the populations--- modules– names, understanding the bucket may be called different things--- full range of ways to present Patient registry (E.g., PCP panel) Know the population- look at the sub populations Using panels- look at different conditions (opioids, diabetes) HCs can choose a variety of conditions to focus Managing the care of that population *Transition note: Accountable care requires identifying who is held responsible for orchestrating care—tests—if not within the org—then who beyond the HC (specialists) are needed
- Tierney Risk- Stratification– only way we have risk scoring may be because Medicaid managed care sends it to us or your eCW autocalculate– if you have the opportunity to risk score– or getting it from a partner– Medicaid authority Example– risk score and now look at that data– identifying how we can do different--- or digging deeper and noting who you will focus on more specifically People may ask– how do you risk stratify? Off in the verbal component--- payers will provide risk attribution--- more of the org responsible is on how do you use that data once you have stratified? How do you decide within the population who is making those decisions?
- Tierney Example: Care of the individual– means we have the dashboard when they arrive for the visit– colonscopy gets ordered– came in and it was ordered– dashboard was the care of the individual– individual dashboard back to pop health Data is overarching concept– what is the type of data? Improvements, patient health outcomes, experience, ROI
- Tierney Managing transitions in care--- ping shows whether they’ve been admitted– getting the care team into action--
- Centralized vs Decentralized examples: -Triage calls -Diabetes – patients here today and patients -Homeless patients
- Data– from playbooks– screenshots Medicare- Bethany Margaret- 2 Mary- 3 Double check with Tierney on bullets**** 3 people Adding urgent care/24 hour advice line Beth Combining---
- Mary WHOs -Reduce no shows for initial appointment -Brief -Issues can be resolved in the single visit Chelsea- Intent--- Quick recap of the way that patients get from medical to BH
- Mary Planned Care in Behavioral Health Delivery of Integrated Services D: we’ve created this collaborative care dashboard that allows BH to ensure that all care that is needed is delivered Transition: in addition, we are using a data-driven approach to enusring patients in medical who need BH services are proactively made know.approached…
- Mary--- revise the slides**
- Mary The role of the nurse in our agency is to assist both medical and behavioral health. One of the most common ways I support BH is through nursing visits. Nurses have their own independent schedule where following protocols, standing orders and directed orders, we can assist our patients and providers outside of their other appointments. Every patient on a controlled substance agrees to a controlled substance contract or agreement which entails routine substance monitoring and drug testing for patient safety. This is a common visit for nurses where they collect a drug screen from the patient, provided education on medication safety and check in on their status, potential side effects, potential substance abuse, and more, and report back concerns to the provider. Often nurses help BH providers through medication reconciliation visits, side effect surveillance and education when starting new medication, routine medication prepours, EKGs prior to medication initiation, medication counts, and much more.
- Mary
- Sent to April Joy- Beth Definition– April Joy--- where people work, play live and learn– provide statistics** SDOH--- Give less that are controversial– Revisie these bullets– Destinction between further upstream factors— Beth– noting that they are well familiar on this– using a formal tool CMS.. What do you do? Take home– webinar onto it’s self– SDOH screenings– very important that people are looking at it– think about coding– codes have direct ties to risk scores– reimbursement
- Beth/Mary
- Tierney Make it more general on the strategy*** Chaning the JD--- changing what’s on their plate– scope of practice to leverage to do this work--- creating a place for the framework for this thinking– Ratios/staffing--- are those the right things on their plates? Staff and time.
- Intent is that this is the conclusion– Need to determine bullets for this Health catalyst--- moving to pop. Health increase in efficiency--***