PQP & Social Determinants of Health NC Medical Society Population Health Collaborative 9/14/2017 Amy Messier, MD, Medical Director Lydia Newman, MPP,

Transcription

1 PQP & Social Determinants of Health NC Medical Society Population Health Collaborative 9/14/2017 Amy Messier, MD, Medical Director Lydia Newman, MPP, Executive Director physician Quality Partners

2 Physician Quality Agenda PQP Who We Are NHRMC Strategic Plan MSSP Population System Efforts in a Shift Towards Value PQP s Efforts to Address Social Determinants for MSSP NHRMC s Broader Efforts Around Health Equity

3 Physician Quality Partners PQP - Partnering with providers to navigate through value based payment reform. Providing the organization, infrastructure, support and education to make it easy for providers to put patients at the center of care. Providing the right care to the right patient in the right setting.

4 NHRMC 5 year Strategic Plan Mission: Leading our community to outstanding health Success Measures X # consumer touches Total system savings of $X X # of covered lives Focus Areas Strategic Initiatives Access - Expand access for sick and healthy patients - Build out network (sites, distribution, primary care and specialty) - Increase price and cost transparency - Partner with retail - Establish digital strategy & virtual platform Value - Engage providers to standardize care - Create personalized experience for patients - Establish post-acute network - Create focused facilities that are highly reliable - Innovate payer contracts and utilize bundles Health Equity - Capitalize on and expand community partnerships, including long term support services and behavioral health - Manage employee risk - Build out care continuum - Create healthy business opportunities - Increase our understanding of and capabilities to manage risk - Enhance cultural competency Service & Operational Excellence Quality Financial Health Patient Engagement Culture of Innovation & Engagement Organizational Design & Infrastructure Analytics Governance Provider Alignment --Opportunity to rethink our role in population health, social determinants of health/health equity --New efforts being developed through entire NHRMC system, via PQP, and with other strategic partners

5 Physician Quality Partners NHRMC/PQP Population Health Initiatives 2013: BCBS Com/MA SS 9,000 Lives 2014: PQRS GPRO 2015: HQEP 5 Service Lines 2016: MSSP 17,000 Lives 2017: MIPS/MACRA 2019: Medicaid Reform??? Bundled Payments Employee Health

6 Physician Quality Partners- Providers MSSP: CIN: Track 1, Providers 3 Tax IDs NHRMC s Residency programs & NHRMC Physician Group Practices (2 TINS) 1 External Private Practice Practice Composition Family and Internal Medicine traditional and residency programs Surgical residency Cardiology Oncology Rheumatology Psychiatry (IP) Ob/Gyn Gastroenterology Urology Neurology 591 Providers 5 HQEP programs Surgical Services General Surgery Orthopedic Surgery Neurosurgery Pathology Anesthesia Pediatrics Neonatology Pediatric Surgery Specialty Practice Hospitalists MSSP Providers

7 PQP MSSP Patient Characteristics Attributed lives less Risky from demographics perspective 6% ESRD vs 8% for all MSSP 9% Disabled vs. 13% for all MSSP 3% Duals vs. 7% for all MSSP 87% Aged Non-Dual vs. 78% all MSSP However, practice composition matters: 5X higher incidence of HIV (have an HIV clinic) 30-33% higher rates of Lymphoma, Breast, Prostate, and other Cancer rates (have Oncology practice) 10X higher normal rates of diabetes with acute complications 30% lower rate of diabetes with chronic complications Average rate of diabetes without complications Low Obesity, Depression REAL or HCC problem?

8 PQP MSSP Utilization Lower than average on Hospital/SNF Utilization Hospitalization Rates (260 vs. 313) Readmit Rates (147 vs 163) SNF Use (42 vs. 56) ED use (566 vs. 698) Lower than average admission rates for COPD and CHF Higher Average on CT Utilization Procedure Spending per Patient Laboratory and Other Test Spending per Patient Part B drugs per patient (but higher HIV and Cancer) Can you shift site of service? Large primary care group - FFS

9 System Wide Efforts for Pop Health Readmission Reduction Efforts Hospital Perspective Improving Care Transitions from Hospital to Home Must Haves Pharmacy medication review, education, and filling of Rx before discharge Discharge phone call within 48 hours Leave with appointment to PCP scheduled Complex Patient Management NHRMC Community Paramedics Community Care of the Lower Cape Fear for Medicaid and MSSP Transition Care Managers Improving Care Coordination with SNFs Discharge Telehuddle Preferred Partnership SNF Geriatrician partnership project

10 System Wide Efforts ED Patient Assistance Center Located in the PAC office in ED Lobby Staffed 7 days a week from 8a-8p by 2 nurses, Licensed Social Workers and Case Manager. Care coordination at the front door Work to link Familiar Faces with the right care/medical home Community partners stationed in PAC office (BH Coastal Horizons, Hospice) Next steps center for communication (SNF, outside MD)

11 System Wide Efforts for Pop Health Building practice capacity to manage complex patients Notification to PCP of ED, hospitalization and SNF visits Post Discharge Transitional Care Visits with Providers CCM programs for chronically ill patients PharmDs embedded in practices to work on Medication Reviews, counsel patients on adherence, etc. Largest practice also embedding LCSWs to provide patient care

12 System Wide Efforts for Pop Health Expanding Access to Care Expanding primary care capacity CFM open access to pediatrics Trying to move to call or come philosophy to reduce unnecessary ED use Implementing process for direct referral from ED to practices with indicator of urgency level (0-3 days, 4-7 days, etc.) E-visits

13 System Wide Focus on Quality Driving Quality in the Ambulatory Care Setting Using AWVs to Sustain Attribution and Drive Quality Initiatives Rooming Standard Work to close care gaps AWV standard work to drive at all preventative measures Purchased Retinal Camera Developing standard work of report retrieval and upload from HIE Using EMR tools and Quality Reports to drive continuous improvement Point of Care Alerts, Care Gap reports, Choosing Wisely, Healthy Planet Clinical Pathways CHF Tying provider and staff compensation to quality metrics Peer Performance Committee Achieved Level 3 PCMH for Largest Practice HCC Education

14 System Wide Focus on Quality Driving Quality in the Ambulatory Care Setting

15 PHYSICIAN QUALITY PARTNERS SOCIAL DETERMINANT STRATEGIES

16 Introduction Lydia Newman, MPP Executive Director of Clinical Integration & Physician Quality Partners 1. PQP s Efforts to Address Social Determinants for MSSP 2. NHRMC s Broader Efforts Around Health Equity

17 Why SDOH Matters so Much ACOs Accountable for Total Cost of Care But only 10% of Health Outcomes Driven by Care We Provide 80% behaviors, environment, and social/economic factors

18 Patients Carry Many Heavy Burdens Big effort to address each patient s needs Even bigger efforts required to solve them at population/community level

19 Social Determinants Journey Building on NHRMC Work on Access and Quality PQP Adding Predictive Analytics/Risk Segmentation Complex Care Management to Address Patient Needs Beginning Journey Upstream to Address Root Causes Risk stratifying patients Applying Interventions to address each patient s barriers Beginning work in community to address health equity

20 PQP Risk Segmentation for MSSP Data Driven Interventions 1. Segmenting Risks at Granular Level with CCNC Tools 1. Admission Risks Day Admission Risk & 12 Month 2. Pharmacy Risks 1. Adherence Risk 2. Drug Interaction Risk 3. High Risk Medication Risk 4. Opioid Fill Risk Day Mortality Risk 4. Impactability Scores 1. Transitional Care Impactability Score ROI for TC Services 2. Care Management Impactability Rising Risk population 2. Putting Actionable Information in Hands of Many A. Data in CareImpact (CCNC Tableau Tool) and Scores in Epic 3. Tailoring Interventions to Address Individual Risks

21 Risk by PCP Care Impact Tool Care Impact Tool ADT of ED and Admit Info. Married to All Risk Data Depicted Infinite Ways, Sortable for Number of Purposes

22 Actionable Data In Many Hands Low Risks Patients Not Seen/ Needing AWVs Schedulers Practice Visits to Address Care Gaps Address HCCs Sustain Attribution of Patients High Admission Risks 30-day and 12-Month Admission Risks Schedulers, Providers, PharmDs, CCMs Proactive MD Appointments to Prevent Admissions Medication Reviews with PharmDs in practices CCM Engagement Complex Care Management as Needed High Pharmacy Risks Adherence, Discrepancy, High Risk Medication, and Opioid Risks Schedulers, PharmDs/Providers Proactive Appointments to Prevent Admissions Adherence Risk--Affordability and Side Effects Discrepancy Risk--Med Review/Reconciliation Treatment Therapy and Opioid Risks- Review and discuss with providers and patients,

23 Actionable Data Drives Interventions of Many Mortality Risk Probability of Mortality in Next 90 Days CCMs/ PAC Nurses/Inpatient Care Managers CCMs/Providers review and refer to palliative/hospice CCHIE pings RNs in PAC in ED to review/refer to palliative care/hospice team (Driving a lot of new engagement) Inpatient Care Managers discuss on provider rounds/refer to inpatient palliative care Complex Care Management Impact Score Provides ROI for Complex Care Management Interventions CCMs/PQP review Rising Risk indicator can use proactively to engage those not necessarily in ED or hospital Get in for appointments Link care management Transitional Care Impact Score ROI for Complex Care Management Interventions for Admissions/ED visits Paramedics/CCLCF Complex Care Managers Community Paramedics or CCLCF based on geography, diagnosis, etc. Both entities do home visits, med recs, assessments, linkages to services, etc. Also use scores to impact ED visits

24 Importance of Home Visits Complex patients --Needs not easily identified/addressed in office visit or by phone --Requires relationship building, MI training, empathy and detective work --PharmDs critical for complex med review Mr. Jones- Patient with diabetes and falls/infections Lost his wife, children live in Florida, lives in rural NC/socially isolated Sold car to pay bills Can t get to church, pharmacy, store, and MD practice too far away, Inherited home in Florida and has one in NC, 2x mortgages Financially stressed, food insecure CM requires broad plan to manage complex needs Started with problem at hand: healing infection Diabetes education nutrition, medication adherence Financial help with prioritizing bills, getting help from children selling home Social/Spiritual--Getting church members to pick him up for church Nutrition--Linking to Meals on Wheels & church food boxes Transportation--Changing to VA practice closer to home/linking to community transportation services And he is more straightforward than many dementia, lack of supports, many stories

25 SNF Strategies Reduce SNF Utilization, LOS, and Readmissions 1) Hospital Mobilization Project Deconditioning during hospital stay cause of SNF admission Efforts to prevent falls contributing to lack of mobilization/increased deconditioning 2) Family Medicine Residency Home Visits Target patients high risk patients who can t come to clinic Physician, Pharmacist, and care manager Take practice visit to home that includes SDOH H&P Falls Risks Care Giver Support ADLs Environment Nutrition Spiritual health Code Status Most Form

26 Reducing SNF LOS and Readmissions 3) SNF Discharge Pilot for MSSP Geriatrician reviewing high risk MSSP discharges to SNF Convey her expected plan of care and length of stay to SNF Use Care Manger Following Up with SNFs Calling SNF at transition to ensure effective transfer made Calling again at expected discharge date, ensure patient on track, has home health, PCP appointment, PCP has discharge paperwork, etc. Follow up with patient to confirm home health arrived, PCP appointment in place, have transportation, etc.

27 Swimming Upstream: Health Equity NHRMC Strategic Plan Focus on Health Equity Employees Starting with Cultural Competency of own Employees Using workforce to impact community through volunteerism Community Gardens, Food Drives, Book Drives, Engaging Community Adding Needed Services Uber, NA and AA for inpatients, Diaper Bank, Meals on Wheels Partnering with community organization formed to stop cycle of youth violence in neighborhood Helping conduct community needs assessment Determining our role in filling identified gaps

28 Swimming Upstream: Health Equity Reducing Health Disparities Statistically significant differences between Blacks and whites within MSSP data in disease burden and utilization Picked up by Priority Scores, but what do we do to change/do differently? Population % of Total % of White Pop Total MSSP 100% 86% 10% Dual Status 8% 5% 30% CHF 7.2% 6.9% 11% % of Black Pop Diabetes w/complications 8.24% 7.27% 17.2% Diabetes w/o comp 13.8% 13.2% 19.1% Renal Failure 2.4% 2.25% 4.14% Admit rate per 1000 (per claims) Readmit Rate per 1000 (per claims) Palliative Care Indicator 5.4% 4.8% 11.24% TC Priority 29.3% 28.3% 41.5%

29 Cost per beneficiary down $177 per patient ($3 M total) since per beneficiary down $177 per pa interventions began Q All MSSP Cost up $221, FFS up 1,366 (FFS deducted non utilizers in Q1 2017)

30 Cost per Dual down $3,572 ($1.85 MM), (In Part Due to SNF Pts out of attribution 1/1/17) All MSSP cost up $379, and FFS up $1,284

31 Outcomes Component cost per beneficiary on short term hospital down $48 All MSSP up $73 All FFS up $395

32 Hosp. rate down 22 per 1,000 = 378 fewer per year Admissions continuing to decline vs. all MSSP and FFS constant

33 Readmit Rate top quartile, 14.7%

34 Physician Quality Partners