Texas Tech University Health Sciences Center is transforming their population health management through implementing care teams enabled by technology. They are focusing on chronic conditions like diabetes and cardiovascular disease. Their goals are to improve outcomes, decrease costs, and reduce disparities for their large patient population in West Texas. They are using the Kryptiq CareManager platform to integrate data, risk stratify patients, coordinate care among teams, and engage patients to help achieve these aims. The webinar discussed best practices for clinical redesign around care teams and how technology can help overcome barriers to effective chronic disease management.

1. Transforming Population Health
through Care Teams and Enabling Technology
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2. TRANSFORMING POPULATION HEALTH
Through Care Teams & Enabling Technology
FIERCEHEALTH IT WEBINAR
JULY 17, 2014

3. Confidential 7/17/2014 Slide 3
» Trends and forces driving the
transformation of healthcare delivery
» Clinical care redesign, including
key barriers, new IT solutions, and
best practice models
» Texas Tech University Health Sciences
Center—population health objectives,
approach, and progress
» The story of Kryptiq CareManagerTM
,
a market-leading PHM solution
» Interactive Q&A
TODAY’S DISCUSSION

4. Confidential 7/17/2014 Slide 4
» Dr. Ogechika Alozie
Chief Medical Information Officer
Texas Tech University Health Sciences Center at El Paso
» Greg Caressi
SVP Healthcare and Life Sciences
Frost & Sullivan
» Dr. Jaquelyn Hunt
Chief Population Health Officer
Kryptiq and IHI Fellow
» Nathan Loveless
Regional Vice President
Kryptiq
OUR SPEAKER PANEL

5. TRENDS & FORCES
IMPACTING PHYSICIAN PRACTICES AND
INTEGRATED DELIVERY NETWORKS

6. Confidential 7/17/2014 Slide 6
» Healthcare initiatives—Triple Aim,
population health management, mobile
health, patient engagement—are to identify
and intervene to improve outcomes
Heart Disease
Stroke
Cancer
Diabetes
Hypertension
Obesity
More than 75% of healthcare costs are due
to chronic conditions (CDC, 2009)
Source: Frost & Sullivan
TARGETING CHRONIC CONDITIONS

7. Confidential 7/17/2014 Slide 7
Source: Frost & Sullivan
PROCESS
CHANGEANALYTICSINTEGRATIONDATA
We are creating
millions of useful
data points,
from a wide
variety of
sources…
…But the data is
provided in
separate solutions
which prevent
getting a holistic
view of the patient
Predictive analytics
has arrived…Natural
language processing
will become a
commodity…
…But working with
only part of the data
Analytics alone cannot
transform healthcare.
Analytics need to
create actions, with
prompts and
information embedded
in workflows
(not in stand-alone
platforms)
HURDLES TO REACHING PROMISE OF DIGITAL HEALTH

8. Confidential 7/17/2014 Slide 8
GREAT LEAP FORWARD TO ACCOUNTABLE CARE
ANALYTICS
» Actionable information?
» How is it delivered?
» At what cost?
CARE DELIVERY SHIFTS
» Where to start?
» How to impact patients?
» Fix it earlier?

9. Confidential 7/17/2014 Slide 9
Source: Frost & Sullivan
INPATIENT
CARE
WELLNESS
SERVICES
AMBULATORY
CARE
HOME
CARE
PATIENT
ENGAGEMENT
DATA
ANALYTICS
IMAGING
DIAGNOSTICS
mHEALTH
CHRONIC
MANAGEMENT
CDS @ POC
INVESTMENTS TO MEET ACCOUNTABLE CARE GOALS
CONDITIONS OF FOCUS
» Diabetes
» Cardiovascular conditions
» Chronic Obstructive Pulmonary Disease (COPD)

10. Confidential 7/17/2014 Slide 10
Source: The Institute for Health Technology Transformation, and Frost & Sullivan
» Success in PHM depends to a large
degree on changing the culture of
healthcare providers
› Acceptance of data
› Utilization of data in changed processes
› Tracking and adjusting at individual and
organizational levels
» Solutions that can support change
management have a greater impact
» Impactful solutions have been tested
and incubated in healthcare provider
organizations
Define
Population
Identify
Care Gaps &
Stratify Risks
Engage
Patients
Manage
Care
Measure
Outcomes
AUTOMATED &
ONGOING
 Data Integration
 Analysis
 Reporting
 Communications
& Alerts
PHM IS A FOCUS OF INVESTMENT

11. Confidential 7/17/2014 Slide 11
Improving chronic care means addressing the following issues (ICIC):
Sources: Improving Chronic Illness Care, and Frost & Sullivan
Rushed practitioners not following
established practice guidelines
Lack of care coordination
Lack of active follow-up to ensure
the best outcomes
Patients inadequately trained to
manage their illnesses
Provide guidelines and individual
patient measures vs guidelines
Unified platform to share information
+ actions with care team
Dashboard of individual status and
follow ups needed for providers
Patient interaction, information and
motivational tools
OVERCOMING BARRIERS TO CHRONIC DISEASE CARE

12. CLINICAL CARE REDESIGN
KEY CHALLENGES, EMERGING SOLUTIONS, AND
BEST PRACTICE MODELS

13. Confidential 7/17/2014 Slide 13
POPULATION HEALTH MANAGEMENT CAPABILITIES
High Functioning
Primary Care
Care Management
Cohort Management
Patient Engagement
Quality & Change
Management
Care team design, aligning work to licensure
Every patient, every time, every where
Support for frail and high need cohorts
Patient outreach and activation
Guiding organizational transformation

14. Confidential 7/17/2014 Slide 14
APPLYING TEAMS TO CARE

15. Confidential 7/17/2014 Slide 15
TEAMS AS A HEALTHCARE INTERVENTION
Shojania KG, et al. Effect of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control:
A Meta-Regression Analysis. JAMA 2006;296:427

16. Confidential 7/17/2014 Slide 16
THE FACTS
» This existence of primary care services improves Triple Aim outcomes
HOWEVER
» 52,000 = additional PCPs to care for population by 2015 (25% increase from 2010)
» 54.9% = average amount of recommended care received by American adults
» 22.6 hr/day = time required for a PCP to address all acute, preventive and chronic
care for a 2500 patient-panel
» 48.1% = PCPs reporting chaotic work pace
» 78.4% = PCPs reporting low control over their work
» 26.5% = PCPs reporting burnout
McGlynn E, et al. The Quality of Health Care Delivered to Adults in the United States NEJM. 2003;348:2635-45.
Petterson SM, et al. Projecting US Primary Care Physician Workforce Needs: 2010-2025 Ann Fam Med. 2012;6:503-9.
Linzer M, et al. Working Conditions in Primary Care: Physician Reactions and Care Quality. Ann Intern Med. 2009;151:28-36.

17. Confidential 7/17/2014 Slide 17
ALIGN KNOWLEDGE & ECONOMICS

18. Confidential 7/17/2014 Slide 18
CONFIGURATION OF THE TEAM
Core Team
2
Paneled
Providers
2-4
Team Medical
Assistants
1
Patient
Relationship Rep
1
Care Coordinator
(MA or LPN)
1
Advanced
Practice
Practitioner
(non-paneled)
Case
Manager
Behaviorist
Clinical
Pharmacist
Diabetes
Educator
Home Health
Nurse
Extended Team

19. Confidential 7/17/2014 Slide 19
PROVEN RESULTS

20. TEXAS TECH UNIVERSITY
HEALTH SCIENCES CENTER
POPULATION HEALTH OBJECTIVES, TECHNOLOGY
REQUIREMENTS, AND OUTCOMES

21. Confidential 7/17/2014 Slide 21
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
» Texas Tech University Health Sciences
Center El Paso, the Texas Tech University
System’s fourth university, has a mission to
provide education, research, and patient care
to far West Texas and beyond.
» Trained close to 4K healthcare professionals
and treated close to 1.5 million patients
» Leader in education and patient care with
research studies underway in the areas of
infectious disease, neuroscience, cancer,
diabetes and obesity

22. Confidential 7/17/2014 Slide 22
» Collaborate with area hospitals
and health centers
» Improve the health of the
community
» Decrease disparities in
minority and rural populations
PURSUING THE “TRIPLE AIM”

23. Confidential 7/17/2014 Slide 23
DEVELOPING A SUSTAINABLE MODEL

24. Confidential 7/17/2014 Slide 24
PRIORITIZING THE CHALLENGES
» Care delivery
transformation—
team-based, aligned,
managed
» Clinical, financial,
patient-supplied data
» Identify data sources
needed to promote clinical
change

25. Confidential 7/17/2014 Slide 25
» Identify chronic disease groups to
measure
» Patients risk-stratified based upon gaps
in care or uncontrolled conditions
» Interventions scheduled according to
practices guidelines and care team roles
» Care coordinated by providing consistent
view across the teams
» End result should be improved outcomes
› Cost containment may follow
ENABLING OUR PHYSICIANS & STAFF

26. Confidential 7/17/2014 Slide 26
Processes
MEASURING & OPTIMIZING PERFORMANCE
*Sample Data – For Illustration Only
Outcomes

27. Confidential 7/17/2014 Slide 27
» Embrace cultural and organizational change
» Expand practice of PHM to additional patient populations
and targeted subgroups
» Continue to improve key quality performance
indicators to recognize upside
» Enhance patient satisfaction by focusing on core measures
» Leverage technology to automate tasks,
streamline communication, and improve outcomes
TAKING THE NEXT FEW STEPS

28. Confidential 7/17/2014 Slide 28
» Multi-modal outreach based upon
patient characteristics, risks, and
preferences
» Patient scorecard to support
informed conversations and
self-management
» “Surround sound” approach to
complement existing engagement
tools, including patient portal
FUTURE PLANS - ENGAGING OUR PATIENTS

29. KRYPTIQ CAREMANAGER
ENABLING CARE TEAMS WITH CLINICAL AND
FINANCIAL DATA AT THE POINT OF CARE

30. Confidential 7/17/2014 Slide 30
» Clinics and group practices pursuing
PCMH initiatives
» Integrated delivery systems focused on
resource optimization or value-based
payments
» Require provider-led health risk
management delivered at
the point of care
COLLABORATING TO SOLVE PROBLEMS DIFFERENTLY

31. Confidential 7/17/2014 Slide 31
» Data ingested from
multiple sources
» Populations stratified
according to clinical
and financial risk
» Hidden opportunities
in patient cohorts
identified using
predictive modeling
PRIORITIZING PATIENT COHORTS
Stratify at-risk segments of the population

32. Confidential 7/17/2014 Slide 32
» Unwarranted
variation in care
reduced
» Care team practices
at the height of
licensure
» Patient is an active
member of the
care team
SUPPORTING CARE TEAMS AT THE POINT OF CARE
Optimize workflows in the clinic

33. Confidential 7/17/2014 Slide 33
» At-risk populations
stratified to receive
appropriate care
» Resources are
aligned for cost-
effective care
» Patients receive
personalized
messaging,
coordinated across
organization
ALIGNING TEAM TASKS, RESOURCES, & CARE PLANS
Coordinate resources across the enterprise

34. Confidential 7/17/2014 Slide 34
» Omissions,
commissions, and
gaps reduced
» Greater visibility to
enable appropriate
interventions
» Care history across
the continuum
TAPPING INTO THE SURESCRIPTS NETWORK
Synchronize care throughout the community

35. Confidential 7/17/2014 Slide 35
“Deepest EHR
workflow integration”
MARKET LEADER IN POPULATION HEALTH
INTEGRATED
51 customers,
7 years peer-reviewed results
Begin with single clinic,
Scale to entire system

36. Confidential 7/17/2014 Slide 36
QUESTIONS?
“CareManager really is a very
powerful tool. It allows staff to
function at the top of their licenses,
can be time-saving, and most
importantly, improves the care
we deliver.”
SUE SCANLIN
CHIEF TRANSFORMATION OFFICER
VP POPULATION HEALTH
CONTINUUM HEALTH ALLIANCE

37. THANK YOU
FOR MORE INFORMATION OR A DEMO:
collaborate@kryptiq.com
www.kryptiq.com

38. Questions

39. Thank you for joining us!
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