Built to Last: Our Population Health Model University of Utah Health Julie Day / Annie Mervis

Transcription

1 Built to Last: Our Population Health Model University of Utah Health Julie Day / Annie Mervis March 9, 2018 Phoenix, Arizona 1

2 Key components of a population health strategy what do you think? Using your cell phone Text To: xyz123 In the message box write one or two words that you consider key to a population health strategy 2

3 Objectives 1. Articulate the elements of a working population health management infrastructure 2. Understand the elements of a successful integrated behavioral health model 3. Identify useful measures of success within a population health integrated model and how to work with the community to build reporting capability 4. Understand the approach to creating a value-based contract 3

4 4

5 Population Health A Little Background 5

6 Population Health Management PHM means the proactive application of strategies and interventions to defined groups of individuals across the continuum of care in an effort to improve the health of the individuals within the group at the lowest necessary cost. Healthcatalyst 6

7 Aims of Population Health Increased patient engagement Better patient self-efficacy More appropriate utilization of health care resources Decreased ED visits Decreased admissions/readmissions INCREASED QUALITY OF LIFE DECREASED COST OF CARE 7

8 Our Team s North Star To proactively enhance patient engagement by establishing therapeutic relationships that result in better quality of life and lower health care costs in a cost effective, sustainable manner. 8

9 Risk Stratifying the Population Is Foundational 9

10 Diagnoses, ED visits, Hospitalizations Limited mobility, Limited Socialization, Depression Limited number of diagnoses-fairly stable May need tests updated Health Maintenance Healthy Health Maintenance

11

12 The CPG Population Health Model 12

13 Diagnoses, ED visits, Hospitalizations Limited mobility, Limited Socialization, Depression 13

14 RISK ADJUSTING THE POPULATION EPIC Foundational Risk Score is currently used for adults Pediatric Risk score was developed internally ADULT RISK SCORE Age # of Hospital Admissions # of ED Visits Chronic Conditions COPD Diabetes CHF Liver Disease Mental Health: Depression No PCP Medicaid Coverage PEDIATRIC RISK SCORE # of Hospital Admissions # of ED Visits # of outpatient visits Breathing problems Mental Health: Anxiety Depression Outpatient medications Medicaid Coverage 14

15 What are the Building Blocks? A like-minded multidisciplinary team Care Managers Social Workers Clinical Pharmacists Carved out paid time for Care Conferences with the Provider and team 15

16 Population Health Strategies INTRADISCIPLINARY CARE CONFERENCES Attendees: Provider, MA/RN, Care Manager, Social Worker, Clinical Pharmacist. Frequency: Care Conferences are held monthly for each provider. Patient identification: Referral from provider Considered high risk on risk registry or based on external utilization data from payers. 16

17 Referring to the Population Health Team 1. Warm Hand-off Introduce the patient to the team member(s) while patient is in clinic. This results in a higher probability that the patient will engage with our services. Often, we can resolve an issue at that time. 2. Consult in EPIC to appropriate service(s) Our referral team will outreach to the patient and set up a future appointment with us. 3. Talk to team member to request Care Conference Discussion 17

18 Team Functions - PROVIDER Establish trusting relationship with patients Facilitate patient engagement with team members (Refer to appropriate team members) Attend team conferences and contribute to the development of patient care plan Analyze and collaborate on needs of high risk patients 18

19 Provider Measures Referrals to Care Management Social Work/GATE Clinical Pharmacy Quality outcomes Patient Experience Easy to understand explanations Listened to Answered Questions Understands what is important to you Respects what you have to say 19

20 Team Functions Care Manager Coordination of care and resources for patient s medical and overall health needs. Home Health/Skilled Nursing Facility/LTAC placements. Coordination of insurance benefits (i.e., Medicare, Medicaid, PCN, commercial). Longitudinal outreach and monitoring of patient s progress toward care plan goals. Coordination of community resources. Assessment of barrier impacting patients health and/or ability to access health resources effectively. Coordination of Care Team Conferences Management of High Risk Adult and Pediatric Registries. Living Well Program Home Visits 20

21 Care Management Measures Percent of high risk patients with a care plan Goals Treatment Goal Lifestyle Goal Contingency Plan (what to do if something goes wrong) Volume of Touches Calls In-person MyChart Volume per Panel Volume per provider Time Tracker 21

22 22

23 Team Functions Social Worker Short term, problem-based psychotherapy (3-5 sessions) Depression/Anxiety Screening Gate Consults Health Behavior Assessment Interventions Coordination of resources for behavioral health needs. Behavioral Health Crisis Intervention (suicidal ideation) APS/DCFS cases and referrals Housing 23

24 Social Work Report for Calendar Year

25 Team Functions Clinical Pharmacist Comprehensive Medication Management (Clinical Practice Agreement) Diabetes Hypertension Hyperlipidemia Asthma Polypharmacy/Medication reconciliation Medication Education to improve understanding of medication regime. Increase medication compliance Adverse Events Monitoring Tobacco Cessation 25

26 Clinical Pharmacy Measures Number of medication reconciliations done Trend AEs Percent of key chronic medications that are being refilled MTM programs established with number of enrollees: Diabetes, Hyperlipidemia, Hypertension, Asthma 26

27 Clinical Pharmacy Metrics 27

28 Team Functions-Nurse Prevention Education Chronic Disease Education Medical record requests from outside facilities DME Screenings Training and workflow development 28

29 Nurse Measures Volumes for: Individual Education Sessions Group Education Sessions Trainings accomplished Screenings accomplished 29

30 SHARED OUTCOMES 30

31 Epic Healthy Planet Primary Care Adult Risk Measures 31

32 Team effect to improve A1C < 9 on a cohort seen by clinical pharmacy July 2015 June

33 What happens at a Care Conference? What issues are facing Jabba the Hut? Poor Diet? Substance Abuse? Mobility? Depression? Social Support? Financial Issues? Identify the issues and together figure out a plan and goals to discuss with the patient. 33

34 The Longitudinal Plan of Care This is the Place for Sharing! 34

35 How do we manage transitions? 35

36 36

37 37

38 How do we support reliable care? Managing Gaps in Care Registry Outreach Care Navigation Center Bulk Outreach Birthday letters MyChart Center-based teams Point of Service Management Pre-visit Planning 38

39 How do we engage teams in quality improvement? Monthly Team Process Improvement Meetings Review current measure performance and workflow Identify and prioritize barriers Develop interventions Decide on process measures to collect on the floor to monitor implementation of intervention Review impact on quality measure Providers paid average RVU for team meeting time 39

40 40

41 FY18 Depression screening project 41

42 CMS Quality Payment Program Preliminary

43 43

44 One Riddle Being Solved 44

45 Missing Data Community Clinic patients utilization in facilities outside our system Collaboration with our Statewide Clinical Health Information Exchange 45

46 chie Data Uses Daily ADT reports pushed from chie to care managers Hospital admits Hospital discharges ED discharges Used for outreach and to schedule follow-up with PCP Next LACE score to risk stratify patients The big picture dashboard Hospital Admissions per 1000 ED visits per 1000 Patients with > 4 ED Visits Avoidable ED Visits Next 30 day Readmissions Rate Total Cost of Care 46

47 DRAFT 47

48 48

49 Lessons Learned Community-based Dashboard development is an iterative process Language barriers: Technical vs. Operational Face to Face matters 49

50 This program has been going from strength to strength and I would be loath to see it compromised in any way, as it is a foundational success upon which we should build. - Dr. David A. 50

51 Pause for Audience Participation Using your cell phone Text To: xyz123 In the message box write one or two words that depict components of the Population Health Management strategy just described. 51

52 Deeper Dive Into Behavioral Health Integration 52

53 The Problems That Need To Be Solved PCP varying confidence in addressing behavioral health concerns Encountering behavioral health concerns lead to: Provider burnout Interference of clinic workflow 1 in 4 adults suffer from a diagnosable mental disorder (Brian & Behavior Research Foundation, BBR, n.d.)

54 January 2014 February ,000 of 291,350 visits in the University Community Clinics had a co-morbid mental health condition 41% No Co morbidity 59% Co-morbid 54

55 55

56 Goals of Integration Increase availability of behavioral health services within the medical model PCP support in addressing their patients behavioral health needs Improve patient clinical outcomes and satisfaction through integrated care 56

57 57

58 Identified Challenges Limited resources for medication management Limited resources for mental health providers due to contractual carve outs and burdensome administrative processes Limited access to mental health providers Challenges navigating the mental health system Limited community resources Social systems breakdown 58

59 One Lesson Learned Co-location and a standard model practice led to Continued limited access Little communication at team level Fundamentally separate practices 59

60 Made the Move to Full Integration Partnership with Community Clinics, Community Physicians Group, UNI, Department of Psychiatry, and College of Social Work Chose to focus on comprehensive care of patients, remove any barriers for any patient Embedded Social Workers into hallways shared with primary care providers 60

61 No behavioral health needs Behavioral health needs discovered Social worker + patient Real-Time Care Team Coordination Triage Assessment Short-Term Therapy Sessions (3-5 sessions) Groups Community Resources/ Referral to specialized services Coordinate with Population Health Connection to internal psychiatric resources Patient Advocacy Crisis Intervention 61

62 One Way to Generate Revenue Health Behavior and Assessment Intervention Codes 62

63 Pause for Audience Participation Using your cell phone Text To: xyz123 In the message box write one or two words that depict components of the integrated behavioral health program just described. 63

64 Getting On Top of Contracting 64

65 One Contract Deal 65

66 The Details on Potential 66

67 STAR Visits: Addressing 90% of HCCs in 60% of Patients 67

68 80% Adherence to HEDIS/STAR Measures 68

69 Other Components of the Contract 69

70 Lessons Learned Quarterly reporting/evaluation is too frequent Double check language in contract to ensure a win/win Start with partners who will be flexible in working to create a win/win 70

71 ROE= COA/TPI Healthcatalyst 71

72 RETURN ON ENGAGEMENT 72

73 Text a one word idea you can use when you return to your organization. 73

74 Questions? ROE= COA/TPI 74