This document discusses linking population health and medical management in the military health system. It covers utilizing population health data to identify populations, assess health status, forecast demand, and manage demand. It also discusses capacity management, evidence-based care and prevention, program evaluation, case management, utilization management, and disease management as parts of a medical management model. Key resources mentioned include the Department of Defense Instruction 6025.20, Population Health/Medical Management Guides, Medical Management Webinars, and the Milliman Inpatient & Outpatient Guidelines.

1. Session 11b: Linking Population
Health and Medical
Management
CDR James Ellzy, MD, CMQ
Teaching Faculty, DeWitt Army Family Medicine
Residency
& Immediate Past Director of MHS Clinical Quality
james.ellzy@amedd.army.mil
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2. Outline
• MTF Utilization of Population Health
• MTF Utilization of Medical Management
• TMA Resources
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3. 11-3
11b - 3

4. Population Health - Outcomes
Where we were... Where we are moving…
FOCUS ON DISEASE FOCUS ON HEALTH
• Sub optimal satisfaction
• Enrollment • Increase appropriate access
• Appointment system • Improve population health
• Claims processing • Enroll and assess needs
• Sub optimal points of access • Primary disease/injury prevention
• Advice/Triage/E.R. • Clinical practice guidelines
• Highly episodic utilization • Demand management
• Many unplanned visits • Referral management
• Lack of continuity • Case management
• Decreased “health status” • Ensure continuity of care
• Increased satisfaction & loyalty
INTERVENTION PREVENTION
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5. Why do we care?
• Because leadership is tracking it…
• Gaps exist in quality of care…
• Persons with disease/risk cost more…
• We work in a financially constrained
environment
• Improves outcomes, productivity,
satisfaction
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6. 11-6

7. Population Identification
and Assessment
Identification Assessment Data resources
• Who are… • What is the health • Medical record reviews
• The eligible status? • Health risk assessment
beneficiaries? • What are the lifestyle • Health related behavior
• Who is… risk factors (behaviors)? survey
• Enrolled to the MTF? • Who needs clinical • MHS Population Health
• Who is… preventive services? Portal
• Enrolled to your • What is the prevalence
clinic? of chronic disease?
• Who is… • Who are the high SCENARIO:
utilizers of services? Who is the
• Being seen in your
clinic? population at
each of your
three MTFs?
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8. 11-8

9. Demand Forecasting
• Requires:
• Accurate population identification (size, gender, age)
• Knowledge of:
• Health care needs of the population (imms & other CPS)
• Prevalence of disease/conditions within the population
• Clinical practice guidelines (including VA/DoD CPGs)
• Operationally defined & system-required demands (pre-
deployment requirements, physical exams, overseas
screening, etc.)
• Resources:
• Utilization Reviews (historical data such as chart reviews
and M2 queries)
• Demand Forecasting models
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10. 11-10

11. Demand Management
• A collection of proactive interventions focused on reducing unnecessary
health care utilization while encouraging the appropriate use of health care
resources.
• Strategies:
• Increasing SELF-CARE Strategies & Patient Education
• PCM Assignments (Right patient mix & distribution)
• Nurse Triage
• Message Center
SCENARIO:
• Making the most of every visit How could
• Immunizations at acute visits Colonel Smith’s
• Oral prophylaxis at dental exam appointment utilization have
• Medication refills at every visit
been better
• Optimizing ALL team members managed?
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12. 11-12

13. Capacity Management
Matching the quantity and
quality of healthcare services • Provider availability
provided at the MTF with the • Provider type needed
needs of the population.
• Support staff
• Ancillary support
Factors affecting capacity requirements
Management:
• Readiness requirements
• Patient demand
• Physical space
• Appointment types
• Equipment needs
• Open Access
• Group Appointments SCENARIO: Any pertinent issues
discussed yesterday afternoon?
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15. Evidence-Based Care
and Prevention
• The provision of healthcare using a
systematically developed, research-based
approach
• Identifies people with or at risk for chronic disease
• Provides patients & families:
• Evidence-based information & tools (e.g. CPGs)
• Multidisciplinary team to follow plan of care
• Referral to resources, as needed (e.g., case
management, disease management)
• Health promotion and/or patient self-management
education
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16. Evidence-Based
Healthcare Goals
• Improved Quality of Life SCENARIO:
What 3 chronic
• Higher Functional Status diseases of Col
• Self-Management Smith do we have
VA/DoD CPGs?
• Fewer Hospitalizations/Acute Visits
• Improved Quality of Care
• Reduced variation
• Decreased Costs  More Resources Available
for Prevention Strategies
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18. Program Evaluation & Feedback
• Implementing Clinical Practice Guideline (CPG) is
NOT enough
• Measure outcomes to evaluate your program’s
processes and performance
• Service required clinical metrics
• Use the Population Health Portal on CarePoint
• National benchmarks (examples)
• Healthcare Effectiveness Data and Information Set
(HEDIS®)
• Healthy People 2020
• Joint Commission-ORYX
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19. Medical Management Model
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20. Case Management (CM)
• Definition:
• A collaborative process under the Population Health
continuum that assesses, plans, implements,
coordinates, monitors, and evaluates options and
services to meet an individual’s health needs
through communication and available resources to
promote quality, cost-effective outcomes.
• DoD Medical Management Guide 2009
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21. Case Management (CM)
• Goals:
• Promote quality, safe, and cost-effective care.
• Promote utilization of available resources to achieve clinical and financial
outcomes.
• Facilitate appropriate access to care.
• Collaborate with the patient/family, physician, healthcare providers, and
others to develop and implement a plan that meets the needs and goals
of the patient.
• Develop individualized patient plans of care.
• Offer objectivity, healthcare choices, and self-management solutions.
SCENARIO: • DoD Medical Management Guide 2009
How could Col Smith have benefitted
from Case Management?
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22. Case Management (CM)
The MHS has three primary goals for CM:
• Improve the care, management, and transition of recovering Service
members.
• Broaden the application of CM to include beneficiaries with complex needs
and at-risk beneficiaries before they require complex care.
• Evaluate the impact of CM on the quality and efficiency of military health
care.
Additional goals applicable to caring for wounded warriors are to:
• Assist the recovering Service member in receiving quality medical and
behavioral health (BH), which may include lengthy inpatient stays and
transistions between facilities or between outpatient medical and BH
services.
• Assist the recovering Service member and his/ her family in understanding
the recommended treatment (including BH services) and in receiving timely
access to that treatment.
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23. Utilization Management (UM)
• Definition:
• An organization-wide, interdisciplinary approach to
balancing cost, quality, and risk concerns in the
provision of patient care. UM is an expansion of
traditional Utilization Review (UR) activities to
encompass the management of all available
healthcare resources, including Referral
Management (RM).
-DoD Medical Management Guide 2009
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24. Utilization Management (UM)
• Goals:
• Maintain the quality and efficiency of healthcare
delivery by:
• Providing patients with the appropriate level of care.
• Coordinating healthcare benefits.
• Promoting the least costly, most effective treatment
benefit.
• Determining the presence of medical necessity
-DoD Medical Management Guide 2009
SCENARIO: How could Col Smith have benefitted from a working
Utilization Management Program in this Multi-Service Market?
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25. Disease Management (DM)
• Definition:
• An organized effort to achieve desired health outcomes in
populations with prevalent, often chronic diseases for
which care practices may be subject to considerable
variation. DM programs use evidence-based interventions
to direct patient care. DM programs also equip the patient
with information and a self-care plan to manage his/her own
health and prevent complications that may result from poor
control of the disease process. The term “condition
management” includes non-disease states (e.g.,
pregnancy).
-DoD Medical Management Guide 2009
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26. Disease Management (DM)
• Goals:
• Improve clinical outcomes
• Increase patient and provider satisfaction,
• Promote appropriate utilization of resources
throughout the MHS
• Purpose:
• Improve the quality of life for individuals by
preventing or minimizing the impact of a disease or
chronic condition.
-DoD Medical Management Guide 2009
SCENARIO: What diseases of Col Smith’s should be
part of a Disease Management program?
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27. Medical Management
Guidance
• Department of Defense Instruction (DoDI) 6025.20
(dated Jan 2006)
• Population Health/Medical Management Guides
• Available: www.tricare.mil/OCMO/publications.aspx
• Medical Management Webinars available. Schedule
at www.tricare.mil/tma/ocmo/webinars.aspx
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28. Milliman Inpatient
& Outpatient Guidelines
• Enterprise-wide license for evidence based guidelines that
supports outpatient and inpatient care (replaced McKesson’s
Interqual on the inpatient side).
• Clinical judgment still needs to be used
• As a commercial product, it doesn’t always match up with the TRICARE
benefit. TRICARE rules must be followed in their application and use!
• Other details
• Updated annually
• Requires an account/password,
• Free for MTF personnel use (paid by TMA)
• Username: mhs
• Password: referral
• Access link via: http://careweb.careguidelines.com
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29. Milliman Inpatient
& Outpatient Guidelines
Ambulatory Care:
Imaging & Diagnostic Testing
DME & Injectables Inpatient and Surgical Care:
Referrals & Rehab Services Actionable Criteria
Detailed Care Pathways
General Recovery Guidelines: Observation care guidelines
Expanded decision support Integrated Quality Measures
Long-term acute care Easy evidence access
Evidence-based complex Patient Information Package
treatments
Problem oriented guidelines Behavioral Health Guidelines:
End-of-life guidance Clinical indications &
alternatives for admission
Recovery Facility Care: Detailed discharge criteria
Clinical indications Partial hospital care planning
Problem-oriented guidelines Flexible recovery courses
Detailed treatment plans Alternative care planning
Multiple length of stay measures
Care management tools
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30. Military Health System Tools
and Resources
• MHS Population Health Portal (MHSPHP) on
CarePoint
• Highlights importance of accurate
documentation and coding = improving
data quality https://carepoint.afms.mil
• VA/DoD CPGs & toolkits:
• www.qmo.amedd.army.mil
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31. Questions?
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