Executing on Population Health Project for A Community. Objectives

Transcription

1 D9/E9 These presenters have nothing to disclose Executing on Population Health Project for A Community Objectives Explain a framework for working on population health projects in a community Share examples of what this looks like in the Triple Aim community 1

2 Does your organization or coalition have a clearly articulated purpose statement for pursuing the Triple Aim including what you are trying to accomplish and why? Yes: Every leader in our organization or coalition is very clear on our purpose for the Triple Aim. Somewhat: Our statement of purpose is clear but not every stakeholder can describe it well. Slightly: The description of our purpose is not very clear. Stakeholders in our community have different definitions of the purpose or are not aware of our work. No: We have not yet begun to articulate a clear and compelling statement of purpose for pursuing the Triple Aim. If anyone answered yes or somewhat on the first question Have you built the infrastructure to support the work? Has you community been activated to participate in this work? Have you done the work at scale for your community? 2

3 Definition System designs that simultaneously improve three dimensions: Improving the health of the populations; Improving the patient experience of care (including quality and satisfaction); and Reducing the per capita cost of health care. Design of a Triple Aim Health System Enterprise Define Quality from the perspective of an individual member of a defined population Population Health Individuals and Families Experience of Care Per Capita Cost Definition of Primary Care Health Care Public Health Social Services Integration System Level Metrics Per Capita Cost Reduction Prevention and Health Promotion 3

4 How to Get Started Building Infrastructure Activate Community Learn at Scale Building Infrastructure Leadership and Governance Purpose Team Formation to support portfolio of projects Population Identification Triple Aim Portfolio 4

5 Population Triple Aim Participant Populations Discrete Populations Community- Wide Populations Triple Aim Results Discrete Populations --Triple Aim for a defined population that makes business sense (e.g. who pays, who provides) Community-Wide Populations -- Solving a health problem within the community and creating a sustainable funding source 5

6 Geographic Region Population Examples City- Memphis TN Primary Care Trust- England Everyone who lives within a certain zipcode/postcode 14 Counties in Michigan *The key idea is that your population is everyone within the geographic boundary 6

7 Do you have a clear reason for choosing your geographic population? 1. Is there a way to work on the multiple determinants of health for this population? 2. Can health care also play a significant role in improving the health of this population? 3. Is the the population of interest defined by geographic boundaries - anyone living within the boundary is in the population whether or not they are currently engaged with the health care system? Observations Most heath care workers tend to pick people with a specific diseases and want to focus on that disease and the comprehensive needs of that populations What ever population you choose be sure to work on people and the entire Triple Aim not just a disease 7

8 Action Step 1 Identify a population for which your organization/region/coalition is responsible Describe the population demographics (size, age segmentation, SES, and major health issues) Describe data sources Portfolio Selection 8

9 Genesys Example: Investments and capabilities Initiative Sample Projects Investments Capabilities Primary Care PCMH transformation Practice Coaching Certification Patient Engagement Care Transitions Safety Community Engagement IT transformation Aligned Payment Systems Health Navigator Self- Management Support Pre-Post hospital support Longitudinal Care Plans Clinical Integration Pathways High reliability training Safety event tracking and reporting Daily Leadership Huddles Safe Routes Healthy Schools Advanced Care Planning IT and process transformations EMR, Registry, RHIE Pioneer ACO Bundled Payment Opportunities PCMH Incentives Partnerships with commercial Development and testing Staffing and training Testing, scale up and spread Leadership commitment Training costs Data systems Time Partnerships Staff and tools Leadership commitment Relationship building Development and t ti Practice Coaching Measurement Patient engagement skill set Improvement science Learning System Leadership Measurement Improvement science Community collaboration Population perspective Project management Physician engagement Cutting edge knowledge Risk taking Relationship building Rapid redesign Fl ibilit Tayside s approach to Triple Aim Integrated Resource Framework Older People Early Years Steps to Better Healthcare Communities in Control Health Equity Strategy Population Health Data and Measurement Collaborative Leadership Working with Communities as Assets Creating Shared Intelligence through Data Building Capacity and Capability Shift in focus from disease to population health 9

10 Action Step 2 Based on the population you chose in the first action step what projects would you consider for this population? Will these project accomplish Triple Aim or just one of the aims such as the health aim Does anyone have a good example of a Triple Aim portfolio? How to Get Started Building Infrastructure Activate Community Learn at Scale 10

11 Integrated Health System for Achieving Triple Aim Results at Scale Community PCMH Specialty Other Employers Schools Health Plans Social Services Public Health Community organizations; faith communities 11

12 Levels of Community Activation Three Levels of Activation: Activating individuals: Community organizing, storytelling, facilitative leadership Activating organizations: Community/Stakeholder collaboration and governance Activating communities Understanding community assets, participatory decision making The Role: Understanding how they influence shared community goals Sharing personal stories and an urgency for change Building up leaders around them Participating in readily available venues for designing solutions Activating at the Individual Level What Activation Might Look Like: Single mother trained as a community health worker coaching a newly pregnant woman about opportunities for and importance of prenatal care. Local Boys and Girls Club volunteers spreading the word to residents about an upcoming community listening session around a health need. 12

13 The Role: Understanding and communicating local role in impacting the health of the community Pooling resources to solve a health need Developing shared goals and methods for shared decision making and collaboration Activating at the Organizational Level What Activation Might Look Like: A church taking a small segment of time during services to preach the connection between spiritual well-being and health. Referral of the family of a child seen in clinic for a well-child visit to a paralegal services team (resident in the clinic) to get their landlord to fix building code violations in their apartment. Activating at the Community Level What Activation Might Look Like: Local community coalition creates an online inventory of assets in the community accessed by any organization or resident. Community hosts a series of resident listening sessions each Wednesday night at local library to design solutions to address a health need. The Role: Engaging community in creating a shared purpose to address a particular health need Understanding assets within the community and engaging stakeholders to address the shared purpose Locating sustainable funding structures to keep the work going Creating venues for residents to engage in decision-making 13

14 When we started out This is much bigger than any one organization or outsider can fix Where could collective action help achieve the Triple Aim? How do we turn collective action into results? Needs-Focused Map McKnight & Kretzmann,

15 Assets-Focused Map McKnight & Kretzmann, 1996 A Shift From Needs-Focused Assessment Needs Assets Focus on deficiencies Focus on strengths Result in fragmentation of responses to local deficiencies Make people consumers of services; builds dependence on services Give residents little voice in deciding how to address local concerns Build relationships among people, groups, and organizations Identify ways that people and organizations give of their talents and resources Empower people to be an integral part of the solution to community problems and issues 15

16 Healthy Northeast Initiative Community Asset Map How to Get Started Building Infrastructure Activate Community Learn at Scale 16

17 Components of a Learning System for the Triple Aim 1. System level measures 2. Explicit theory or rationale for system changes 3. Segmentation of the population 4. Learn by testing changes sequentially 5. Use informative cases: Act for the individual learn for the population 6. Learning during scale up and spread with a production plan to go to scale 7. Periodic review 8. You need people with skills who can help with all of the above From Tom Nolan PhD, IHI Potential Triple Aim Population Outcome Measures Dimension Population Health Measure 1. Health Outcomes: Mortality: Years of potential life lost; Life expectancy; Standardized mortality rates Health/Functional Status: single question (e.g. from CDC HRQOL-4) or multi-domain (e.g. SF-12) Healthy Life Expectancy (HLE): combines life expectancy and health status into a single measure, reflecting remaining years of life in good health 2. Disease Burden: Incidence (yearly rate of onset, avg. age of onset) and/or prevalence of major chronic conditions 34 Experience of Care Per Capita Cost 3. Risk Status: Behavioral risk factors include smoking, alcohol, physical activity, and diet. Physiological risk factors include blood pressure, BMI, cholesterol, and blood glucose. (possible measure: a composite Health Risk Appraisal (HRA) score) 1. Standard questions from patient surveys, for example: Global questions from US CAHPS or How s Your Health surveys Experience questions from NHS World Class Commissioning or CareQuality Commission Likelihood to recommend 2. Set of measures based on key dimensions (e.g., US IOM Quality Chasm aims: Safe, Effective, Timely, Efficient, Equitable and Patient-centered) 1. Total cost per member of the population per month 2. Hospital and ED utilization rate and/or cost 17

18 Design of a Triple Aim Enterprise Define Quality from the perspective of an individual member of a defined population Population Health Individuals and Families Experience of Care Per Capita Cost Definition of Primary Care Health Care Public Health Social Services Integration System Level Metrics Per Capita Cost Reduction Prevention and Health Promotion Segmentation of the Population 18

19 Population Segments Employers 600,000 Population Children Seniors Low Income Population Segments Bridges to Health Model Splits populations into 8 segments 1. Healthy 2. Maternal-infant health 3. Acutely ill, likely to return to health 4. Chronic conditions with normal daily function 5. Serious relatively stable disability 6. Short decline to death 7. Repeated exacerbations, organ system failure 8. Multi-factor frailty, with or without dementia Lynn, Joanne, Straube, Barry M., Bell, Karen M., Jencks, Stephen F. and Kambic, Robert T., Using Population Segmentation to Provide Better Health Care for All: The 'Bridges to Health' Model. Milbank Quarterly, Vol. 85, No. 2, pp , June

20 Testing and Learning Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Plan Study Do Improvement Guide Ed 2, Langley, Nolan, et.al. 20

21 Multiple Plan-Do-Study-Act (PDSA) Cycles Changes That Result in Improvement A P S D A P S D A P S D Wide-Scale Tests Implementation of Change Hunches Theories Ideas A P Follow-up Tests S D Small Scale Test Learn from Informative Cases 21

22 Frank Frank is a 79 year old widower with Chronic Obstructive Pulmonary Disease (COPD), Heart Failure and Diabetes. He lives alone. Frank is very anxious as he is often very breathless and feels unable to manage. He has phoned the practice of his primary care physician on several occasions requesting a home visit and over the last year he has frequently been taken to the local emergency department, after he has dialled 911. He has been admitted to hospital on 7 occasions in the last year and now keeps a small packed suitcase by his chair. Spread and Scale-up 22

23 5X Scale-up Reduce cost and improve care for socially complex Number of people System issues to address 5 1. Form a team of volunteers 2. Find people through referrals Full time team 2. Redesign of practice 3. Cooperation of hospitals for data 4. Assess outcomes Grant funding for operations 2. Consistent population outcomes ? ?? 15,625 1.??? Oversight and Guidance 23

24 Oversight and Guidance Make clear connections to strategic direction Set the pace with monthly and quarterly 1-2 hour reviews Expect effective explanations of progress and obstacles from the team Revise as appropriate every days Extract common themes among projects Triple Aim Participants 48 Over 100 Sites Since

25 HIP & The Triple Aim Laurie Mireles PhD HIP Policy & Outreach Director Profile of Santa Cruz County North South Disparity South of San Francisco Bay Area 260,000 residents North University, silicon valley, 88% graduated from high school South agricultural, 82% Latino, 53% graduated from high school Fragmented Health Care 3 competing hospitals 3 medical groups Independent practices No public hospitals Community clinics at capacity Culture of collaboration on common ground issues 25

26 51 Current Mission Statement To unite public and private health care providers and key community stakeholders to advance high quality, high value and patient centered care to improve the health of all members of the Santa Cruz County community. 26

27 High Level Measures Population Health Experience of Care Cost of Care Health Adjusted Life Expectancy (HALE) Health risk (childhood obesity)* Ambulatory Sensitive Admissions Kids Coverage* Regular source of care* HEDIS Avoidable ED Visits 30 day readmissions Per capita costs Hospital days/1,000 Ed Visits/1, : Common Ground Relationship Coalition Building HIPC & Safety Net Clinic Coalition Initiative Focused Healthy Kids Go for Health Hospitalist Linking Make Your Wishes Known Clinical messaging Project Connect Policy Advocacy and Public Information CAP goal setting, L99, HC reform, Kids coverage Events, columns, websites, videos Local, State, Fed Alignment National Reform: CBCCN, SNCC Capacity, Patient Navigators Medi Cal Waiver: Complex Care and Coverage Expansion Health plans: Alliance Q/C Based Incentives, P4P, P CMH, ACO Foundations Coalition Building, Preparing for National Reform Beacon II 2010: Systems Improvement Care Coordination and Coverage Health Navigator Healthy Kids County wide OERU planning Baby Gateway Quality Improvement SNCC: Patient Centered Medical Homes Focus on Complex Patients Avoidable ED Improving transitions of care Design Framework Outcomes Evaluation Triple Aim: Cost Pt Experience Population Health Coalition & Trust Building Ever Present HIPC, SNCC, HK, PVG, CCHI, Health Equity, columns and communications 54 27

28 Portfolio Example: Baby Gateway Funders Collaborative Partners A Little Background Many Medicaid eligible infants have a gap in coverage because they enroll late or not at all 2003: California creates deemed eligibility for infants born to mothers on Medicaid this includes a new, short, 6 question enrollment form 2007: deemed eligibility underutilized, gaps persist 2009: Packard Foundation contacts HIP regarding problem of underutilized baby enrollments. Santa Cruz County has high ED use for babies

29 High ED Visits for infants are associated with Decreased access to primary care Parents not understanding the role of the medical home Insufficient connection with the primary care provider Lack of availability of same day office appointments BG was a Process. 2011; Enrollment Assistor begins making well baby apt 2011; Application assistor finds that mothers are forgetting their provider. A sticker is printed w provider contact info and attached to take home materials 2010; Committee finds that providers are re enrolling babies in Medicaid and begins: 1) provider outreach; and 2) printing cards for providers informing them that the baby has been enrolled 2010; All new mother s are oriented in the What to do if your Baby Get s Sick book 2009; Enrollment assistor begins helping families identify Primary Care Provider 6/2009; BG launches at 1 hospital. The enrollment assistor is tasked with completing Medicaid forms 29

30 What Does Baby Gateway Do? For Medicaid mothers: Enrollment Assistors meet with new mothers in the hospital Enroll eligible infants into Medicaid Assist the mother in selecting a medical home for the newborn Make appointment for infant s first visit to medical home Distribute the First 5 Kit for New Parents Orient the mother to the What to Do if Your Child Gets Sick book Remind parents the importance of preventative care For all mothers (regardless of insurance) Distributes the First 5 Kit for New Parents, Orient the mother to the What to Do if Your Child Gets Sick book Goals of Baby Gateway 1. To achieve seamless health care coverage and access to a medical home for Medicaid eligible infants born in Santa Cruz County. 2. To decrease avoidable emergency department (ED) use for all infants. 3. To support all new parents in creating a safe, healthy, and loving home in which to raise their child. 30

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