Population Health forAccountable CareMay 14, 2012Confidential: Not for duplication or distribution. Subject to revision.
A Population Health Parable Over the last forty years, a rural New England county has achieved the highest health status rank, the lowest chronic disease risk factor levels, and the lowest mortality rate in the state. For 2011, the county was ranked first in the state in health outcomes, despite relatively higher levels of poverty, by the University of Wisconsin Population Health Institute. Health Status Rank Cumulative Risk Factor Rankings Mortality Rate in Ten Years, by County16 16 Four Years, by County Deaths per 10,00015 15 Ten Years, by County14 1413 13 62012 1211 11 60010 10 9 9 580 8 8 7 7 560 6 6 5 5 4 4 540 3 3 2 2 Smoking Weight 520 1 1 Blood Pressure Cholesterol 500 American Journal of Preventive Medicine (Record, N.B.; et al. American Journal of Preventive Medicine 19(1):30-38, 2000) and highlighted by the American College of Cardiology in the report of its 33rd Bethesda Conference (Task Force #3, Preventive cardiology: How can we do better? Presented at the 33 rd Bethesda Conference, Bethesda, MD, December 18, 2001, Journal of the American College of Cardiology 40:579-651, 2002). 2 Confidential: Not for duplication or distribution. Subject to revision.
Shared Success Factors Structured Trained and Actionable Program Assessed and Equipped Health Methodology Engaged “Care Assessment and Health Users Partners” Technology Management “Care partners” who A health status A program Assessed, engaged, combine skills in health assessment and management and more literate assessment, reports that model combining health users with the motivational address health “high touch” agency and data to interviewing, empathic risks and actions in services delivery support more attention, and active the context of and a campaign rational and effective listening to collect clinical approach to user health decisions comprehensive health effectiveness and engagement and information and regulatory health assessment engage health users compliance 4Confidential: Not for duplication or distribution. Subject to revision.
So What?Four federal programs (value-based purchasing, meaningful use of electronic records, avoidable hospital readmissions and the creation of accountable careorganizations) will significantly impact hospitals through the use of Medicare penalties and incentives. In order to qualify for the incentives and avoid penalties,hospitals will have to go beyond simple "check-box" processes and employ new patient engagement strategies that actually work to improve outcomes and the overallpatient experience. Progress to-date is not encouraging. Accountable or value-based healthcare requires that delivery systems assume the financial risk of an assigned population’s health care, previously the domain of health plans. More than 160 such accountable care organizations are making that shift today and the number is growing. This shift has exposed a gap in the accountable care continuum -- the process of enrollee engagement and assessment. Traditional enrollment and the primary care encounter do not: – engage health users sufficiently to “own” their health status and advance that sense of health agency; – conduct a comprehensive health risk assessment; and – develop - with the patient – and manage a personalized prevention plan with anything approaching population health levels of participation and consistency. While CMS reimburses annual wellness visits and preventive services through Medicare, Medicaid, and commercial plans, few providers accommodate them, citing lack of structure, process familiarity, system fatigue, and discomfort conducting the assessments and using preventive services strategically, systematically, and comprehensively. Health systems do proceed, however, to invest in related, more costly, technology, service capacity, and human capital initiatives that will be hampered by the absence of preventive services data. 5Confidential: Not for duplication or distribution. Subject to revision.
Assessment and Engagement: The Missing Step Enrollment & Assessment & Encounter & Verification Engagement Care Delivery Pre-Enrollment: Pre-Engagement Pre-Encounter • Form conversion • Target patient, provider, and site selection • Patient call for appointment • Applicant eligibility • Practice call for follow-up • Provider-patient concentration Enrollment: • Referral • Geographic concentration • Member Eligibility Verification Encounter • Member Enrollment • Payor concentration • Primary Care • Application processing • Data sourcing, extraction, and pre-population • “First contact” care • Enrollment reconciliation • Systems of record (EMR, patient accounts, • Evaluation & • Member Management registries, scheduling, clinical ancillary) management • Payment reconciliation • Demographics, relevant assessment data • Continuous (ongoing) • Risk Management Engagement care • Suspect Claims • Coordinated care • Invitation, scheduling, confirmation • Chart Analysis • Comprehensive care • Health risk assessment • Coordination of benefits (COB) • Specialty Care Post-Enrollment: • Draft personal prevention plan • Primary care referral • Data, eligibility, and payment • PCP-patient review, as needed • Self-referral verification with CMS or health Post-Engagement • Emergent Care • Post-enrollment education • Data cycle management • Strategic servicesConfidential: Not for duplication or distribution. Subject to revision.
Agentic Health – Turnkey Assessment and Engagement Assessment and Engagement Program Management – Practice integration and enrollee – Source, train, equip, and outreach mobilize care partners – Welcoming the patient to the – Maintain assessment software program, conducting the and hardware assessment, and preparing the – Optimize logistics of site, personal prevention plan provider, and enrollee matching – Completing reports for – Pre-populate assessments with individual, primary provider, and data currently available from employer (at appropriate levels insurers’ data and providers’ of detail and confidentiality) systems of record – User guidance on highest value – Ensure availability of completed actions to improve their health data sets to EMRs, patient – Follow-up accounts, registries, scheduling apps, and other systems of record 7Confidential: Not for duplication or distribution. Subject to revision.
The Care Partner Agentic Health trains Care Partners in the skills required to conduct the health assessment and engage health users and their providers in understanding their health and the best actions they can take to improve it. Competency in “person-centered” care where Motivational interviewing and active listening important care support services are provided – Informing and emboldening the patient outside the healthcare system as a shared decision-maker – Family support guidance and ongoing – Uncovering barriers to change that access by telephone or email include physical pain, emotional – Knowledge of and guidance regarding difficulties, financial concerns, and lack of community services that address the risk confidence in one’s ability to change factors that are the focus of the – Assistance in patients setting realistic assessment, including, where established, goals, self-monitoring, harnessing support local Area Agencies on Aging and Aging systems, and engaging their care provider Disability Resource Centers. effectively – Knowledge of and guidance regarding other community support functions Provider and practice support and engagement including home delivered meals, – Engaging the care team to use transportation for shopping, program assessment reports to prioritize and eligibility and benefit counseling, highlight patients’ health risks and translation services, respite care, and appropriate action steps fitness programs – With appropriate privacy protections, Cultural competency, respecting individuals’ aggregating assessment data for use by beliefs, understanding the cultural context in individual physicians, provider practices, which they experience illness and health, and health facilities, and accountable care developing a collaboratively set health plan organizations for performance improvement 8Confidential: Not for duplication or distribution. Subject to revision.
The Assessment: Compliance in Design and Process* Demographics and limited family/personal health history Self-assessment of health status, frailty, or physical/mental functioning Biometric measures (when these data are not readily available from laboratory results or medical records): e.g., overweight and obesity (height/weight, body mass index (BMI), waist circumference), hypertension (systolic/diastolic blood pressure), blood lipids (HDL/LDL and total cholesterol, triglycerides), and blood glucose (blood sugar and hemoglobin A1c levels) Psychosocial risks: e.g., depression/life satisfaction, stress/anger, loneliness/social isolation, and pain/fatigue Behavioral risks: e.g., tobacco use, inadequate physical activity, poor nutrition or diet, * Health risk assessments (HRAs), in conjunction with excessive alcohol consumption, prescription follow-up counseling, coaching, and behavior change drug use for nonmedical reasons, and motor interventions make up the personalized prevention plan, vehicle safety aimed at improving the health and well-being of Compliance with current screenings, Medicare beneficiaries. This approach also applies to a chemoprophylaxis, and immunization non-Medicare population, including privately insured guidelines established by the USPSTF and ACIP adult individuals in both the individual and group (when this information is not available from markets, when an HRA and follow-up interventions are the EMR or PHR) used to promote health and prevent disease. 9Confidential: Not for duplication or distribution. Subject to revision.
Economics Roles Total PMPM – Care Partners – Engage Revenue 8,175,000 11.35 enrollees and capture assessment data – Data Partners – Pre-populate Expenses Direct Labor Care Partners 4,200,000 5.83 assessments with available data and ensure presentation Data Partners 840,000 1.17 of updated data to systems of- record Management 1,414,000 1.96 – Management – Train and Sub-Total 6,454,000 8.96 deploy Partners while providing regular progress Direct Non- reviews with designated client Labor 312,000 0.43 leaders Size* – One Care Partner / 1,000 Sub-Total 6,766,000 9.40 enrollees – One Data Partner / 5,000 Contribution 1,409,000 1.96 enrollees Contribution – One Manager / 15,000 Margin 17% 17% enrollees – One Program Director / 60,000 enrollees Enrollees 60,000 * fully operational program at 60,000 engagements and assessments annually 10Confidential: Not for duplication or distribution. Subject to revision.
Approach: Consultation to transfer Enterprise Pilot Selection Pilot Evaluation Program Launch Evaluation and Launch & Program Design Know what current Develop a pilot HAE Conclude pilot or set Commence program and planned programs program proposal that an endpoint for pilot launch with 12-24 and services affect or is representative, evaluation month timetable to will be affected by the replicable, run-rate. implementation of Review pilot measurable, and HAE performance, identify bounded in time and strengths and cost Array populations, weaknesses sites of service, and Establish evaluative potential HAE Develop refined criteria and beneficiaries program proposal of communications plan appropriately larger Develop an HAE Launch pilot scope methodology, staffing plan, and program Review proposal with management model program and client incorporating the leadership organization’s needs Revise and ratify and capacities Duration: 6 months program proposal Duration: 6 months Duration: 6 months 11Confidential: Not for duplication or distribution. Subject to revision.