Future State: Evolving Care Models for Improving Population Health. Town Hall Discussion

Transcription

1 Future State: Evolving Care Models for Improving Population Health Town Hall Discussion

2 Today s Presenters Monica E. Oss Chief Executive Officer, OPEN MINDS Rachelle Glavin Director of Clinical Operations, Missouri Coalition for Community Behavioral Healthcare Scott Green Senior Vice President, CareGuidance, Netsmart

3 Why The Focus on Population Health Management? Payer and consumer focus on coordination to improve consumer experience and clinical outcomes Value-based reimbursement and alternate payment models on the increase requires population health management competency for success

4 A Snapshot Of The Market Changes 30+% of Medicare beneficiaries have opted into Medicare Advantage 2.4 million Medicare beneficiaries (nearly 12%) are enrolled in Medicare Advantage special needs plans (SNPs) focused on specific consumer types About 2.0 million consumers dually eligible for Medicaid/Medicare are enrolled in Medicare Advantage Dual Eligible Special Needs Plan 20 state Medicaid plans with health homes enrolling 1.25 million consumers an increase of 25% over 2014 Accountable care organizations (ACOs) cover 12% of the U.S. insured population Vertical carve-outs emerging. In Medicaid, 3 states with vertical carveouts for the SMI population 5 states with vertical carve-out for other populations

5 But... The best practice in care coordination and population health management models is evolving many approaches Models for using data and deploying technology are also evolving What do we know?

6 Top Down Approach to Population Health How is the data analyzed and pushed out to those who can impact the population? Claims Data Applying Analytics Payers? Population Care Manager

7 From Data Insights to Intervention Sometimes the message is lost in translation Care Managers Delayed reporting on analytics Multiple systems used to gather client information Reporting complexities Data presents to Care Team in bulk; not filtered to the user s caseload Insights not presented in a user friendly workflow driven manner Usability is created via workarounds

8 Goals of a Population Health Platform Missouri s Shopping List Access to data in near real-time Minimize and/or eliminate double entry of metabolic screening data Easily assign and manage caseloads Aggregate and display meaningful data in one system (claims data, hospital and ER notifications, metabolic data) Allow for flexible reporting from the aggregate data set at the Coalition and site level Create risk stratification and apply rules logic to the data set Enable population health management

9 A Blizzard of Spreadsheets The frustration of trying to manage populations with spreadsheets You want me to log into another system? Just check your Has the spreadsheet been sorted by caseload? Does the spreadsheet apply rules and logic to the dataset?

10 Case Study A Day in the Life The Missouri Coalition for Behavioral Healthcare

11 Missouri Coalition for Community Behavioral Healthcare 33 member organizations 11,000 staff members 250,000 people served annually Whole state coverage Public Policy / Advocacy Program Management Data Management Training (EBPs, learning collaboratives, conferences)

12 Disease Management Outreach Community Mental Health Centers outreach and engage individuals with a known mental health condition and high Medicaid costs, and who are not currently receiving services from a behavioral health provider. This high risk population is identified by Missouri Medicaid, and a list is sent to providers to outreach. The disease management outreach population enrolled in Healthcare Home account for approximately 74% of the total savings of CMHC Healthcare Home program.

13 CMHC Healthcare Home CMHCs enroll individuals with a serious mental illness, and other chronic health conditions, to receive comprehensive care management and care coordination. Expanded the care team to include nurse care managers, primary care physician consultant, and care coordinators. CMHC Healthcare Home program had a net savings of $98 million in the first 4 years.

14 Previous Nurse Care Manager Workflow Analyzing data for caseload prioritization + reporting DMH sends hospitalization report/ ED alerting Master Client Spreadsheet Medicaid EHR Medicaid Eligibility Health Information Exchange Provider Electronic Health Record Receive monthly reports* from reporting tool Reporting Tool CIMOR Access service and program data? Dated reports have I or someone on the care team already intervened? Performance can determine payment to agency

15 Real-time Data to Drive Outcomes Data is aggregated from various sources in the healthcare ecosystem Aggregating the Data Intelligent Rules Engines Workflow Business Rules Caseload Management Alerts/Notifications Risk Stratification Data Aggregation Population Health Management Platform Care Coordination Interoperability Analytics Outcomes Risk Stratification Optimal management of populations occurs with real-time data from multiple sources Data Sources EMRs/Other Inpatient Ambulatory Behavioral Health Human Services Billing/ Accounting Data Warehouse HIE/ HL7 Laboratory Pharmacy PDMP Justice Alerting System EDIE System HIE/HL7

16 Population Health Platform Missouri Health Home Example Population Health Management Platform Care Coordination Interoperability Analytics Front Line Operations Care Management/Coordination View Quality Measures and Reporting Population Health Data View Missouri Coalition Analytics and Compliance View Patient-specific Data Metabolic Screening Data Claims Hospitalizations Emergency Department Alerts Missouri Department of Mental Health Patient Care Data CMHC EHRs

17 The Quality Measures for Missouri Tracking and presenting the information to the nurse care manager Aggregate View 79% Adult Body Mass Index (BMI) 21% Drill down to the specific clients needing intervention Goal: 70% Asthma Medication Adherence (Adult) Blood Pressure Control for Diabetes (Adult) Blood Pressure Control for Hypertension (Adult) Body Mass Index Control (Adult) Hemoglobin HbA1c Control for Diabetes (Adult) LDL Control for Cardiovascular Disease (Adult) LDL Control for Diabetes (Adult) Metabolic Screening Complete (Adult) Individual Overview Tobacco Use Control (Adult) Visually presenting the whole picture of an individual with metrics that matter

18 Focusing on Interventions Proactively managing population health Population Managed Intervene Hemoglobin HbA1c Control for Diabetes 71% % Goal: 60% ID Name Gender Age Case Manager Arenciba, Victor Brown, Todd Walken, Tonya Jones, Betty A1c Result M 57 Gibson, Janet 8 M 64 Gibson, Janet - F 19 Green, Sue 13 F 65 Gibson, Janet 10

19 Making Data Work for YOU Integrated Care One stop data shop Data real-time Interoperability with EMR Assign and manage caseloads Monitor health risks Ask questions and run reports Measure outcomes I like not having to open so many systems to care for a client. Being able to see the Medicaid eligibility code, missing metabolic screening data, and other details on the individual clients in one location with alerts and more up to date data has definitely helped me become more effective and efficient. Our clients and will receive better care because of the data feed(s); the alerts enable staff to follow up quickly and provide the best care. Also, having easy access to the quality measures is an excellent motivator and makes follow up much more efficient.

20 Population Health Management Automation makes population health management feasible, scalable and sustainable Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare, Institute for Health Technology Transformation, Chase, Alide, et.al.

21 Questions & Discussion