Dual presentation delivered by Pat Posa, RN, FAAN, Population Health Clinical Integration Leader, St. Joseph Mercy Health System, Quality Excellence Leader, Trinity Health and Elizabeth Van Hoek, Population Health Leader, Quality Institute, St. Joseph Mercy Health System at the marcus evans ACO & Payer Leadership Summit Spring 2017 in Dallas, Texas

1. Pat Posa RN, BSN, MSA, FAAN
Population Health Clinical Integration Leader
Elizabeth Van Hoek BSE, MHSA
Population Health Program Leader
April 28, 2017
Leveraging Analytics to Align
Resources and Impact Outcomes

2. • Span 5 counties in Southeast Michigan
• 5 hospitals, over 35 outpatient clinics, urgent care or
specialty centers
• St. Joseph Mercy Hospital
• 550 bed tertiary hospital in Ann Arbor Michigan
• 90,000 ED visits
• Level 1Trauma Center
2©2017 Trinity Health
St. Joseph Mercy Health System
(member of Trinity Health)

3. • Focused on managing our acute care population
through risk stratification of patient with a predictive
model to identify patient needs and align resources
• This included spreading the work across the
continuum (regardless of payors or participation in an
ACO)
• Developed PRISM model - implemented in 2012
- Scored/Risk Stratified patients prior to admission
- Began developing and implementing Care Bundles aligned
with risk strata
• Outpatient providers now leveraging PRISM to help
better manage their populations
3©2017 Trinity Health
Before the ACO Journey

4. 4©2017 Trinity Health

5. • Making a Case for Change with leadership and
multidisciplinary teams
• Predicting Outcomes of Interest and Prospectively
Identifying High Risk Populations with PRISM (risk
prediction model)
• Recognizing and Understanding the Data - PRISM Strata
and Outcomes
• Defining and organizing care with specific risk based
multidisciplinary interventions – PRISM Bundles
• Developing and monitoring new processes - Example
• Continuing to leverage PRISM across the continuum
5©2017 Trinity Health
Key Elements in Leveraging Analytics

6. Making the Case For Change
Leadership and Multidisciplinary Team
©2017 Trinity Health 6

7. • Hospital Perspective: Move beyond episodic care-
can’t just worry about what happens in hospital
• Population Perspective: Now have a defined
population that we are jointly responsible for
utilization, outcomes, cost and overall health.
• Need a care model that is universal and nimble to
respond to the every changing healthcare
environment
7©2017 Trinity Health
Why we need to do things differently?

8. • “From the get-go we engaged a group of nurses, physicians,
staff managers, case management and a care redesign team
as champions to spread the word. We spoke at different
venues where we talked about the program and answered
questions.”
- Joyce Young, RN, PhD, CNO at SJMHS
• “Docs and all providers like data. So when Mark (Cowen)
presented some of the outcomes, especially mortality data,
the buy-in was pretty easy.”
- David Vandenberg MD, Medical Director Outcomes Mgmt,
Vice-Chair Internal Medicine at SJMHS
8©2017 Trinity Health
Using Data to Engage the Team

9. 9

10. Multi-Disciplinary Team with Clear Roles
10
Role Responsibilities
Executive
Sponsor
Provides oversight and direction, removes barriers and engages
executive leadership
PRISM Nursing
Lead
Drives culture and practice change across the organization; leads
ongoing program management; consults with individual
teams/departments to support adoption of PRISM framework
PRISM Physician
Lead
Drives culture and practice change across the organization,
facilitates involvement with medical staff, residency programs, etc. to
support PRISM framework
PRISM
Application Super
User
Lead for web-app set up, training and issue resolution; Liaison to
Quality Institute and Trinity ITS for web-app and PRISM orderable
related issues
(examples: local IT, clinical trainer, or PRISM Nursing Lead)
Project
Management
Time limited role, may be combined with another team role (like
PRISM Nursing Lead or Application Super User depending on skill
set
Process Owners
& Accountable
Leads
Ensures that PRISM scoring and Bundle related processes are
sustained and that the organizations quality and engagement and
outcomes work continues to leverage the PRISM framework

11. PRISM Framework:
Risk prediction tool
©2017 Trinity Health 11

12. PRISM Prediction
• Measures risk of 30-day mortality. Also predicts other
outcomes of interest
• Predicted mortality risk is stratified into the PRISM Scores
(PRISM 1 is the highest risk to PRISM 5, lowest)
• Scores are generated by Emergency Room and Pre-
Procedure staff via a web-based application prior to
hospitalization.
• Launch multi-disciplinary care activities in proportion to the
level of patient need
• Use a common clinical language among inpatient/outpatient
physicians, nurses, other health care team members to
communicate a patient’s risk
12

13. Discernment and Calibration
13
Retrospective Validation
Discernment - AROC Calibration
30-day mortality (0.88)
180-day mortality (0.89)
Palliative status (0.89)
Unplanned Transfer (0.74)
30-day readmission (0.69)

14. 14
What goes into the Prism Formula?
Provided By Clinician:
Currently or within last year:
Cognitive Defect
Other Neurological
Atrial Fibrillation
Cancer
Metastatic Cancer
Leukemia
Currently have:
Respiratory failure
Injury
Heart Failure
Sepsis
Medical vs Surgical Admission
Provided Electronically:
– Age, Gender
– BUN
– WBC
– Platelet Count
– Lactate
– Hemoglobin
– Albumin
– Arterial pH
– Arterial pO2
– Troponin
– Discharged from SJMHS within past
year
– Emergent Admission
Copyright©Saint Joseph Mercy Health System,
Ann Arbor Michigan
The PRISM Score is generated with the most abnormal lab
value available from the previous 30 days. Prospective
Scoring does not require this complete list of lab values
and has been validated based on typical ordering practices

15. 15
PRISM Scoring: Ann Arbor Example
Prospective Scoring prior to bed assignment
Emergency
Department
ED provider
generates score in
PRISM web
application
Bed Manager
confirms score is
complete before
assigning bed and
inputs PRISM score
into PowerChart
Elective
Surgery
Surgical Prep Center
completes score in
PRISM as part of pre-
anesthesia call/
screening (2-3 days
prior to admit)
Pre-Op Clerk views
score night before
and enters score into
PowerChart
Direct
Admit
Bed Manager
completes score in
PRISM once patient
has been accepted
for admission or
transfer
Admitting staff
confirms patient
admission and enters
PRISM score in
PowerChart
Have also developed a complementary Outpatient PRISM score to assist with overall population health

16. PRISM Strata and
Outcomes
What is the data telling us?
©2014 Trinity Health - Livonia, MI 16

17. 30-day Outcomes by PRISM Strata
SJMAA Adult Inpatients, CY2015
17

18. Timing of Interventions Influenced by Risk
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High Risk PRISM 1 & 2
patients face their
highest mortality risk in
the first few hours/ days
of the hospital stay
PRISM score triggers
expedited treatment and
multidisciplinary Care
Bundles
Risk lasts to 180 days
Likelihood of death – measured
for 30 days from day of
admission.

19. Disposition and PRISM:
Informs Work of Case Managers, Social Workers

20. ©2014 Trinity Health - Livonia, MI 20
High risk patients provide lower scores:
Doctor Communication and Staff Responsiveness
20
More FavorableLess
Favorable
Factors may include:
* Longer LOS
* More Handoffs
* More Consultants

21. • Medicare spending per beneficiary
21©2017 Trinity Health
Potential impact beyond acute care

22. ©2017 Trinity Health 22
PRISM Framework:
Risk based patient
care interventions

23. PRISM as a Patient Care Framework:
Mass Customization for Improved Population Management
and Individual Outcomes
23
Assign
PRISM Score
and Pre-
Admit Work
Identify Appropriate setting for care,
Initiate Care and Bundles
Transition
& Discharge
Post Discharge
Follow up

24. PRISM 1 Acute Care: Admission and Care Coordination
Ann Arbor Bundle Example
Physicians
• ED Provider generates PRISM Score prior to bed
assignment
• Verbal ED to Inpatient Physician communication
• Inpatient Provider:
• begins assessment and initial inpatient care
orders prior to floor arrival
• evaluates status changes in person during
acute stay
Nursing
• ED Nurse repeats vitals within 1 hr prior to
transport to bed or calling report
• Verbal ED to Inpatient Nurse handoff
• Inpatient RN:
• greets patients (within 1 hr) upon arrival to floor
(beginning work on PRISM 1 admit checklist)
• notifies physician of change in status, VS
q30min x 4, q1hr x 2, q2hr x 4, then q4hr until
stable
• Rapid Response Team rounds daily
24
PRM
• Ensures score is available for
placement decisions and
documented in Cerner
• Places PRISM 1 patients in
Intermediate Care at a
minimum, ICU if aberrant
vitals in ED
Palliative Care, Case
Management and Social Work
• Case Management completes
initial assessment within 24
hrs (M-F)
• Palliative Care team
addresses Goals of Care,
Advance Care Planning
• Social Work supports
Advance Care Planning
needs
Nutrition
• Completes screen within 48
hrs of admission
• Preferred snack three times
per day provided for all
PRISM 1 - proactively
supplementing meals

25. PRISM 1 Acute Care: Transitions
Ann Arbor Bundle Example
Case Manager and
Discharge Planning Team
• Ensures follow up
appointment is scheduled
for 3-7 days post
discharge
Inpatient Pharmacy
• Provides Medication
counseling prior to
discharge
• Complete post discharge
phone call to review
medications
Physician
• Reviews med changes/high risk meds
with bedside nurse
• Completes discharge summary within
12 hours of discharge
• Orders home care if discharging to
home
• Attempts verbal communication to PCP
or SNF Physician or follows standard
written communication
25

26. Data driving
interventions
Patient Placement
©2017 Trinity Health 26

27. Timing of Interventions Influenced by Risk
27
Mortality rate high risk
patients (Prism 1 & 2)
face in the first few
hours/ days of their stay
PRISM score triggers
expedited treatment and
multidisciplinary Care
Bundles
Risk lasts to 180 days
Likelihood of death – measured
for 30 days from day of
admission.

28. • Placement in Intermediate Care or ICU
(ICU based on acuity)
• Physician begins assessment and initial inpatient
care orders prior to floor arrival
• Nurse greets patients (within 1 hr) upon arrival to
floor (beginning work on PRISM 1 admit checklist)
28©2017 Trinity Health
PRISM 1: Placement and Admission

29. Continuing to
Leverage PRISM
©2017 Trinity Health 29

30. PRISM Bundles Framework: Continued Innovation
30
Expanding Across
the Continuum
• Original Bundles focused on Acute Care processes
• Check In PRISM score now available at the time of ED registration
• Outpatient PRISM prediction rule developed, validated for IHA adult primary
care population ( ~ 200,000 patients) All-payer
• PRISM 1 Bundle implemented at SJMAA and SMML Home Care and 15 area
SNFs
Evolving to
Address New
Learnings
• Chelsea Developing specific PRISM 1, 2 strategies to improve Physician
Communication and Staff Responsiveness
• Physician team member speaks with family daily
• Develop, distribute handout explaining inter-disciplinary rounds and schedule
• Consider conference calls for families not attending IDR
• SJMAA Pharmacy Team using follow up phone call process to provide
medication counseling for PRISM 1 & 2
Integrating
Clinicians and
Teams
• Oakland – Proactive, Anticipatory Rounding: Rapid Response Team rounding
on PRISM 1 patients within the first few hours of admission
• Ann Arbor – Nutrition and Nursing staff implementing “PRISM 1 Snack List” to
pro-actively address malnutrition and related outcomes (Readmissions,
Infections, HAPU)
Ambulatory & ED
Discharges
Acute Care: Admission &
Care Coordination
Acute Care: Transitions
Home Care & SNF
(new in 2016)
As of July 2016

31. PRISM Across Michigan: Sites at a Glance
31
Site Scoring Bundles Implemented Initial Outcomes
Chelsea ED and Surgical
Admits
Acute Care  Unplanned transfers to ICU
 Median time to DNAR
Ann Arbor ED and Surgical
Admits
Acute Care
Home Care PRISM 1
SNF PRISM 1
 30-day Mortality
 30-day Readmits
 Early IP Orders (PRISM 1)
 Palliative Care Consults
Livingston ED and Surgical
Admits
Acute Care  30-day Readmits (PRISM 2)
 Palliative Care Consults
Livonia ED Admits Acute Care
Home Care PRISM 1
SNF PRISM 1
 Median time to DNAR
 30-day Readmits (risk adj.)
 30-day Readmits from SNF
Oakland ED Admits Acute Care currently
being implemented
 30-day Mortality
Grand
Rapids
ED Admits Developing ED Care
Mgmt, Palliative
As of Jan 2017

32. Additional Resources for PRISM
32
• For additional background on the PRISM Derivation and Validation see:
• Cowen ME, Strawderman RL, Czerwinski JL, Smith MJ, Halasyamani LK.
Mortality predictions on admission as a context for organizing care activities. J
Hosp Med, 2013;8:229–235.
• Cowen ME, Czerwinski JL, Posa PJ, Van Hoek E, Mattimore J, Halasyamani
LK, Strawderman RL. Implementation of a Mortality Prediction Rule for Real
Time Decision-Making: Feasibility and Validity. J Hosp Med, 2014;9:720-726.
• If you have questions or would like additional information, please
contact:
• SJMHS Quality Institute at Pat Posa (patricia.posa@stjoeshealth.org) or Liz
Van Hoek (elizabeth.vanhoek@stjoeshealth.org)
Time for Questions??