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Similar to Leading Value Based Care Delivery PKoehrer MGMA Oct 19 2016.pptx (1)
Similar to Leading Value Based Care Delivery PKoehrer MGMA Oct 19 2016.pptx (1) (20)
Leading Value Based Care Delivery PKoehrer MGMA Oct 19 2016.pptx (1)
- 1. LEADING VALUE-BASED CARE DELIVERY Pamela L. Koehrer, MBA, CMPE
- 2. BIG CHANGES AHEAD (STILL) MACRA : VBP :: MU : EHR
- 3. SESSION OBJECTIVES 1. Explain the transformation in health care delivery from episodic care to population health management and understand the impact on patient care. 2. Identify new roles and goals for providers, management and staff in population health management and value- based payment models. 3. Provide examples of best practices related to operationalizing specific mandates.
- 4. ESSENTIAL ELEMENTS OF POPULATION HEALTH MANAGEMENT • Population Health Management (PHM) is one of the core tenets underlying the current healthcare reform movement. • PHM is core to several care models and reform initiatives, namely: • The Triple Aim initiative • The Accountable Care Organization (ACO) concept • The Patient Centered Medical Home (PCMH) model
- 5. ESSENTIAL ELEMENTS OF POPULATION HEALTH MANAGEMENT • PHM can be defined as the proactive application of strategies and interventions to defined groups of individuals to improve the health of individuals within the group at the lowest cost. • When operationalized, PHM is a technology-enabled team sport.
- 6. ESSENTIAL ELEMENTS OF VALUE-BASED HEALTHCARE
- 7. ESSENTIAL ELEMENTS OF VALUE-BASED HEALTHCARE
- 8. ESSENTIAL ELEMENTS OF VALUE-BASED HEALTHCARE
- 9. SHIFT TO VALUE-BASED WORLD
- 10. SHIFT TO VALUE-BASED WORLD • Roles • Goals • Activities
- 11. PROVIDE PATIENTS ENHANCED ACCESS TO CARE 1. What are the current options for patients to schedule appointments? 2. Do all on-call providers have access to patients’ health information? 3. What are the barriers to open access scheduling?
- 12. TRANSITION TO A CULTURE OF PATIENT-CENTERED CARE 1. How can you develop collaborative partnerships with patients and their caregivers? 2. Does your practice use an approach to care that emphasizes relationships rather than episodic interactions? 3. How can you motivate patients to achieve their health goals? 4. What tools are available to promote patients’ self- management?
- 13. Patient-Centered Care Technique: Motivational Interviewing for Diabetes Medication Compliance
- 14. Motivational Interviewing - Diabetes - Pulling His Own Strings Paul Burke Published on Sep 19, 2014 Sample of a training DVD Part 2 of a 2 DVD set) on the use of Motivational Interviewing in Diabetes Care/Diabetes Education. This excerpt includes the "training front load" (explanations of what is demonstrated in the interview that follows). This DVD (entitled "Pulling His Own Strings") highlights skillful use of MI within the evoking and planning processes of an MI conversation with a patient who was recently diagnosed with Type II diabetes. He struggles with self-regulation and with acceptance of his diagnosis. Target behavior is "developing a strategy for better self-regulation. DVD #1, DVD#2, or the set of 2 are available from the Paul Burke Training & Consulting Group. For info please contact info@paulburketraining.com
- 15. EVALUATE INTERNAL PROCESSES FOR CARE COORDINATION 1. How do you follow up on patients with missed appointments or missed screenings? 2. How are you notified when a patient has been to the ER or admitted to the hospital? 3. Does your practice team have established workflows to assess medication reconciliation and adherence? 4. Do you have a pre-visit huddle? How do you flag charts? What is your post-visit process? 5.Do you use shared care planning? How does a care plan impact the patient’s treatment plan?
- 16. ESTABLISH EXTERNAL INFRASTRUCTURE TO COORDINATE CARE 1. What arrangements do you have with other providers in your area? 2. How satisfied are you with access to care for your patients? 3. What protocols are in place for transitions of care and medication reconciliation? 4. What is your process to track referrals? 5. Do you include patient preferences and concerns in the referral process?
- 17. MAXIMIZE AVAILABLE HEALTH INFORMATION TECHNOLOGY 1.How does your practice identify patients who need visits, labs, or other services? 2.What data do you have that can help you identify and stratify your high-risk and complex patients in the practice’s population (utilization, diagnoses, pharmacy data, reports, etc.)? 3.How will you need to deliver care differently to meet the needs of this group of patients? 4.Can your system identify your target population? How do you currently link patients to resources? 5.Does your practice use telehealth options to make patient interactions more convenient; expand geographic horizons; or make care more accessible to those with mobility issues?
- 18. OBTAIN TOOLS AND SKILLS FOR SOPHISTICATED ANALYTICS Has your group ever: •Identified the 5% to 10% of the patient population that, as frequent fliers, drive ED use and admissions? •Used risk assessment tools (e.g., patient self-assessments and case management tools) to evaluate an individual’s health status? •Identified unique patient characteristics that create barriers to care (e.g., transportation, language and health literacy)? •Used a predictive model (e.g., for readmissions or future costs)? •Employed advanced cost accounting approaches to more precisely measure the cost of care?
- 19. ACHIEVE IMPROVED CLINICAL AND AFFORDABILITY OUTCOMES 1.How do you use quality improvement to make changes? • Process improvement projects (e.g., Lean) • Care delivery pilots (e.g., patient-centered medical homes) • Other initiatives that require skillful change management 2.Do you have physician/front-line champions and standardized workflow? 3.How does your practice use data to drive improved care and decreased costs? What workflows do you use to eliminate unnecessary procedures and testing to reduce avoidable costs? 4.Does your practice have experience with a clinical integration model and/or a compensation system that moves beyond relative value units to better align organization and physician incentives?
- 20. Thank you!
Editor's Notes
- MACRA’s (Medicare Access and CHIP Reauthorization Act of 2015) impact on adopting value-based payment models is expected to rival the impact of meaningful use on adoption of electronic health records. Today, there are approximately 750 accountable care organizations are in operation, covering some 23.5 million lives covered under Medicare, Medicaid and private insurers. The shift to value-based payment is in its early stages, but value-based contracts are expected to increase substantially in the next decade. For example, the Centers for Medicare & Medicaid Services has a goal of 50 percent of Medicare payments being tied to alternative payment models by the end of 2018. In addition, Aetna expects that 70 percent of its contracts will be value-based by 2020. Since providers will need to implement alternative payment models to obtain a higher reimbursement rate, they might as well do so during the time frame in which they’ll receive a bonus payment to help offset the risk. These trend toward value-based care will accelerate the demand for new services and technology that enable health systems and other organizations (health plans, Medicaid, community-based organizations, employers and so forth) to jointly manage the health and care of populations — either as an ACO or in an ACO-like fashion. While diverse, these organizations will have a common need to optimize operational efficiency, improve financial management and effectively engage consumers in managing their health and care. As healthcare leaders, you are on the front lines driving the transformation in health care delivery from episodic care to population health management. Your charge is to integrate the people, processes and technology needed to advance value-based care delivery and innovative payment models.
- This session is meant to be introspective, self-reflective and interactive all at the same time. Regardless of where you are on your journey to value-based care delivery, please take this time and use this opportunity to reflect on your progress, improvement capabilities. Then, formulate your own plan for value creation, both as a leader of your medical practice and as an individual healthcare professional in your current role.
- Population medicine and population management are key to redesigning the current volume driven care delivery system to a system driven by quality, outcomes and shared accountability. This is where it all starts for provider organizations that have embraced population health management, and are seeking ways to compete in this new environment. Population health as a concept made an early appearance in 2003 when David Kindig and Greg Stoddart defined it as “the health outcome of a group of individuals, including the distribution of such outcomes within the group.” Populations could be considered as a group of people with diabetes, cancer patients with tumor regrowth, elderly with multiple comorbidities, etc. “Improving the health of populations” was later identified as one element in the Institute for Healthcare Improvement’s Triple Aim for improving the U.S. health care system, along with “improving the individual experience of care” and “reducing the per capita cost of care.” As we know, there is now widespread belief and a growing body of evidence that suggests that at-risk models can help deliver on the Triple Aim. Population medicine requires a comprehensive approach to care embodied in methodologies such as ACOs, PCMHs and new chronic condition care models.
- The population health efforts that most health systems and ACOs are undertaking are aimed at providing better preventive and medical care for the population of patients attributed to their organizations by Medicare, Medicaid or private insurers. Whether participating in an ACO or not, provider organizations should consider building a population health management strategy and addressing related gaps in their information technology capabilities. Minimally, this would include acquiring the capabilities and tools to: Know, characterize and predict the health trajectory that will happen within a population. Engage members, families and care providers to take action. Manage outcomes to improve health and care. Before we get to the best practices for operationalizing the Triple Aim and value-based care delivery, we should discuss what is meant by the term, “value-based.”
- In the past decade, it has become clear that effective healthcare reform requires a comprehensive knowledge and implementation of the principles of value-based healthcare and the “Triple Aim”. Two of the most influential thought leaders of our time and proponents of these strategies are Dr. Donald Berwick and Dr. Michael Porter. Dr. Donald Berwick is the former CMS Administrator and Institute for Healthcare Improvement (IHI) President Emeritus and Senior Fellow. According to Berwick, healthcare reform requires implementation of three aims: Improve the care experience; Improve population health; and Reduce cost. Fragmentation of care has created a need to better measure costs and care. Enter quality measures, pay-for-performance payer contracts, and process improvement methodologies like Lean. Lean thinking involves process improvement through the elimination of waste so that all work adds value. This involves culture change at the organization level. Enter the strategies and tactics to put health reform theory into practice.
- Dr. Michael Porter, Bishop William Lawrence University Professor at The Institute for Strategy and Competitiveness, based at the Harvard Business School, pioneered the concept of value-based care. According to Porter, the core purpose of health care is value for patients. The value formula is based on health outcomes that matter to patients and the costs of delivering those outcomes. To deliver high-value healthcare, delivery must shift from volume to value.
- How does this apply to the real world of practicing clinicians?. High-value healthcare includes the following ingredients, as depicted in the graphic on this slide: patient care, coordination of care, patient engagement, collaboration between care team members and data on the care outcomes, costs and utilization.
- For the visual learners among us, I’ve included another graphic showing how the elements of the healthcare world are shifting. I think Guidewell did a good job of depicting this transformation, mostly by focusing on proactive, patient-centered healthcare and the information sharing among providers. In a nutshell, shifting to a value-based healthcare world requires two “new” mandatory elements: extensive data and IT support and patient and community engagement. 1. Extensive Data and IT Support PHM requires a single data repository that integrates clinical, financial and utilization data from multiple sources across the medical community. This comprehensive view of a patient’s health status is critical to managing care across the full continuum and ensuring patients receive the right care in the right venue at the right time. Advanced data analytics are required to risk stratify the patient population, devise comprehensive care management programs, manage costs and utilization, create disease registries and track progress on quality indicators. Clinically Integrated Networks (CINs) are well positioned to pursue population health management initiatives. They align the clinical and financial interests of hospitals and employed physicians with the broader independent physician community under a common infrastructure. As a single entity, the CIN is capable of managing an array of value-based payment arrangements and as well as benefits from joint contracting opportunities that result from delivering greater value through a demonstrated ability to improve care and control costs. 2. Patient and Community Engagement To be truly effective, population health management initiatives must “touch” two groups: patients who actively seek care and patients who don’t. While care management resources are key, innovative programs will be required to effectively reach both groups. Many experts feel that engaging patients in their own care processes will be the lynchpin to successfully transforming care. The graphic on this slide shows the differences between the “old world” of healthcare, the “new world” and the “future world.”
- To improve care and succeed in VBP world, operationalizing new workflow processes comes down to the “who, what, when, where, why and how” of population health management. This leads to new roles, goals, and activities. Practice leaders need to support and educate so they can fully understand what they are undertaking. Practice leaders can help providers understand their risk in the new healthcare world, as well as the fundamental process, workflow, and behavioral approaches that should be adopted. Providers need to understand the “why”, and buy into trying the “how.” Then, practice leaders can suggest the “who, what, when and where” to effect success. With prompting from practice leaders, providers will be ready to commit to change, to learning and growth, and to achieving improvement within the new world of requirements put forth by stakeholders. These are meant to align incentives and provide the right care, at the right time, and in the right place. Leaders can create an environment of open communication, teamwork and shared accountability for new roles, goals and activities, including the key physician behaviors. Leaders can help introduce and reinforce a common language and an environment of learning about population health, the Triple Aim, and value-based payment programs. Workflow changes center around processes, tools and people. We are trying to change the tire while driving the car. What levers are available for leaders to pull? Do the current process work to achieve the desired outcomes? If not, how far off are they? When providers or staff hit a barrier, leaders can help them regroup and try a new strategy/tactic to break through.
- Take a proactive approach and reach out to your patients. Schedule them for a comprehensive assessment of chronic diseases and/or time for annual wellness preventative visit. Monitor how long it takes to schedule a same-day sick appointment and communicate the availability of urgent, acute triage options to them. Reach out to new patients, those who haven’t been seen in a year or are overdue for a follow up visit. Use telehealth options to engage with patients. Since practices are being asked to focus on patient needs and preferences while guiding patients to the right care at the right time in the right setting. Approaches such as e-mail exchange, after-hours care and patient portals can help you achieve these goals without having to keep the practice open 24-7, but can allow for 24-7 service availability. Open-access scheduling allows for patients to see a provider – preferably their own provider - on the day they call to set an appointment, regardless of the reason for the visit. Practices that have adopted this method have reported improved patient satisfaction, increased productivity and higher physician compensation. Your objectives in this area might include: Provide patients with options for communication such as a patient portal that allows appointment scheduling, prescription refills, care team messaging and virtual visits (eg, email and video capabilities) Make arrangements for 24/7 electronic access to personal health information, including after-hours personnel or on-call providers and a 24/7 call center with RN support Move toward open access (same day) scheduling of appointments Plan appointment types and standing orders to streamline care Develop a process for documentation and follow up on scheduling and clinical advice Provide patients with a documented process for choosing a PCP Develop a process for timely appointments for new patients. Outreach strategies to select population segments to prevent injuries (eg, falls) and promote health and safety
- Your task in leading this the volume to value transition is to reduce the impact of culture, language, lack of resources and other limitations in the care planning process, and to include patient experience in quality improvement processes. Your set of objectives might include continually improvement in these areas: Engage patients so that they understand and embrace their role in the patient-centered care team Enable staff to holistically evaluate patients for strengths and barriers, not just looking at the medical condition but at every aspect of a patient‘s mind and body, including social/family support networks. Understand the challenges of changing behavior and how to guide your patients towards better health Learn about a team approach to engaging patients Overcome cultural differences, language barriers, and low health literacy to effectively assist your patients Help patients understand the need for follow-up appointments, referrals, diagnostic tests, and procedures Develop ways to be more sensitive to non-medical and spiritual dimensions of care Empower your patients to improve their self-management skills and self-efficacy
- A big enhancer of patient engagement and self-management is in providing excellent care coordination. It is important to develop and continually refine processes in your practice to: Develop a process to identify and intervene with high-risk patients Identify and close patient care gaps Outreach to patients with recent hospitalizations and coordinate care transitions Implement a process to include medication adherence and reconciliation at each visit and care transition Reach out to patients who have missed appointments Coordinate referrals and test results Develop a workflow to support annual comprehensive assessment Establish sustainable process for shared care planning that includes self-management support/goal setting/action planning A care plan is a detailed approach to care customized to an individual patient’s needs. Care plans are called for when a patient can benefit from personalized instruction and feedback to help manage a health condition or multiple conditions. A care plan enhances a patient’s plan of care by providing steps to meet identified health goals. The format will vary based on your documentation process and electronic capabilities. There is no single template that must be followed, but there are critical elements that should be included: Collaborative approaches to health, including patient and family participation in care plan Prioritized goals for a patient’s health status Established timeframes for reevaluation Resources that might benefit the patient, including a recommendation as to the appropriate level of care Planning for continuity of care, including assistance making the transition from one care setting to another As we continue through the session, we will further explore these basics and identify how available IT automation can help practices with these additional workflows.
- PHM requires that individual practices establish external processes/infrastructure to achieve coordination of care with the medical neighborhood and community. Objectives for performance improvement in this area could include: Develop more sophisticated relationships with outside providers and community resources over time. Develop tools and procedures to communicate and coordinate patient care. Whether or not your practice is a recognized patient-centered medical home, success in value-based care will require that it provides continuity between settings and collaboration among everyone involved in a patient’s care. Shared decision-making with patients/family members and well-coordinated care promotes better health outcomes: fewer readmissions and medication issues better patient safety and patient satisfaction reduction in duplication of services increased delivery of preventive services. Physicians, care coordinators, and their teams must be empowered with tools that allow them to track patients as they interact with other elements of the healthcare system and to monitor their clinical progress over time. One way to meet this challenge is to use information technology wherever possible to automate care coordination and care management and make it more efficient. Strategic leaders recognize that investing in team-based care today is imperative for success tomorrow.
- Health Information Technology includes all the digital tools you use to manage patient health, such as an electronic medical record(EMR), patient portal, e-prescribing, registries with embedded evidence based guidelines, and clinical alerts. Improved use of technology will impact clinical outcomes and cost of care. Your practice will benefit when you maximize available health information technology (HIT) for evidence-based care delivery and relevant clinical decision support. Stratifying your patient population is one way to identify patients who can most benefit from additional guidance and attention from the practice care team. Patients may be identified and prioritized using information from a variety of reports, i.e. Emergency Room, urgent care, and inpatient admission and discharge reports. Gaps in care can be identified and worked proactively using care opportunities reports. You will need to develop a process for using this information to reach out to patients with chronic conditions, conduct pre-visit planning, and close care gaps. Objectives for this area of PHM might include: Demonstrate improved trends for chronic disease clinical outcome measures Implement a workflow process for high-risk and high-cost reports Demonstrate use of resources for high-risk patient stratification Use reports to review cost of care implications Health care interventions that occur solely through office-based patient or provider interactions will no longer provide the level of monitoring and scrutiny we need to manage the health of individuals and populations. Thus, we must continue to harness the power of technology to engage patients in their care via tools such as patient portals and personal health records, as well as the use of social media, texting and email, and use of telehealth to expand geographic horizons, particularly where needed medical specialists are few in number.
- For organizations looking to enhance their population health management strategies, the HIT platform must be able to collect data from multiple, disparate sources in near–real time, including any EHR, devices used in the home and at work, and other data sources, such as pharmacy benefit managers or insurance claims. These enhanced population health IT solutions support organizations in not only aggregating, but transforming and reconciling data to establish a longitudinal record for each individual within a population. They are able to identify and stratify populations to pinpoint gaps in care, enabling providers to act on information and match the right care programs to the right individuals. More than an EHR module, this IT platform sits “above” the EHR and other sources of data and must be EHR-agnostic. Furthermore, data from multiple, disparate sources must be aggregated into a single, comprehensive view of the patient to drive new insights in care planning, risk stratification, total cost of care and utilization patterns, for example. While a certified EHR certainly provides the necessary foundation to support the shift toward increased accountability, transparency and value, population health requires a range of IT applications and analytical capabilities. For example, expertise in claims data interpretation and risk modeling are core requirements for successfully participating in the value-based transformation.
- The best guides for chronic illness care and preventive care outcomes are evidence-based measures. Use of a population health registry will provide you with data about your patients. Payer portals can also provide you with several reports to help you improve patient outcomes and measure your clinical quality performance. Using a performance scorecard to track your individual and practice-wide performance toward multiple quality measures is another important aspect of leading value-based care. This includes both those involved in pay-for-performance initiatives and/or those payment models that are linked to shared savings. Sample sections of your performance scorecard could include: Acute and Chronic Care Management; Preventive Care; Utilization; and Clinical and Service Quality Improvement. Your practice’s quality improvement objectives might include: Use in-network resources that provide cost savings Use resources to make better informed referrals Decrease utilization, ER visits, and hospitalization Implement quality improvement activities using clinical and utilization data Measure patient and staff satisfaction to monitor quality Evaluating your providers’ commitment to new models of care is necessary so you can successfully deploy operational processes to support the care delivery and business model goals. These questions get to the core of culture development that will facilitate practice transformation to a value-based payment world. Does your practice have: Physicians who are engaged in crafting and ensuring compliance with clinical pathways that optimize and standardize care across the continuum? Cultural acceptance to rate physician performance and identify practice outliers and then move all toward better compliance with evidence-based care? PCPs who round on inpatients or who coordinate with hospitalists and/or intensivists to manage inpatient care utilization and cost? Appropriate physician compensation and alignment of incentives across providers and consistent with value-based payment models, including a funds flow that is transparent and based on objective metrics?
- Start now to get ready to use data and enhanced processes for value-based care delivery in your practice. While MACRA may be a challenge, it also offers a huge opportunity. For those who are well prepared, the incentives can be significant, at over a 25 percent increase in Medicare payments. It always takes time to adapt to new technology and create culture change. The importance of having the right solutions and processes in place will only increase and become more critical as the MACRA era begins in 2017.