Summit Session 9 Using Data to Drive Population Health in an FQHC Network. Presented by: June 15, 2017

Transcription

1 Summit 2017 Presented by: Session 9 Using Data to Drive Population Health in an FQHC Network June 15, 2017

2 Lisa Moon, PhD, RN, LNC, CCMC Advocate Consulting Lois Brown, RN, PHN, CDE, Health Disparities Supervisor Indi Lawrence, RN, Clinical Care Coordinator Indian Health Board- FUHN ACO Partner

3 FEDERAL URBAN HEALTH NETWORK j0pt00f/1/ / /1

4 2016 Network Level Care Management Harness the power of 10 independent FQHC s for Total Cost of Care Decrease practice variation Increase standard protocol use Population health based on claims data trends Care management strategies linked to clinic protocols and evidence-based guidelines Drive performance improvement to clinical quality metrics for IHP Provide education and technical assistance for implementation Support implementation of HIE

5 Data in Usable Format? OPTUM manages claims data and provides monthly reports Reports were excellent, but sometimes difficult to use in health care operations Many single reports Every clinic had a different focus or need The data wasn t intentionally connected back to work in clinic operations for the ACO Reports are sent securely each month to clinics, but; Resource constrained Short supply of onsite data analysts Low technology experience Tableau format was difficult to manage

6 Cohort Identification Care Management Logic Quality Indicators & Outcomes Care Management DATA Strategy Modifiable Risk Care Management Interventions

7 ID / Strat Tool Developed for FUHN Advocate Consulting worked with OPTUM to develop Care Management Logic Identification / Stratification Tool (ID / Strat Tool) provides data in a manageable format to care coordinators, case managers, operation staff and providers. The ID / Strat Tool is paired with Care Management Strategies used in clinic and care coordination. The overall work is tied to evidence-based practice and population health.

8 ID / Strat Tool: Data at Practice Level Provided a better patient list because it flags three types of modifiable risk. Gaps in care Overutilization / Underutilization of health care resources Spending trends Care management rules are weighted so that patients with multiple flags have a higher risk stratification. The ID / Strat Tool looks across all the different reports from Optum and organizes patients in a smaller single data driven cohort.

9 ID Strat Tool at Indian Health Board Indi Lawrence, RN Clinical Care Coordinator Lois Brown, RN, PHN, CDE Health Disparities Supervisor

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11 Introduction To The Indian Health Board Minneapolis o 1971 IHB was established First Urban American Indian clinic o 1986 Joint Commission Accredited o 1990 Federally Qualified Health Center o 2010 Recognized DSME program by ADA o 2012 Health Care Home Certified by MDH

12 Key Characteristics of FQHC s Not-for-profit (Public or private) Provide a Comprehensive Scope of Services Located in or serve a high need community - Medically Underserved Area (MUA) or a Medically Underserved Population (MUP) Govern with community involvement (51%-user Board of Directors) Treat patients regardless of ability to pay

13 Who are health center patients? 1 of 7 Uninsured Persons, including 1 of 5 Low-income Uninsured Persons 1 of 7 Medicaid Beneficiaries 1 of 3 Individuals Living in Poverty 1 out of 4 Minority Individuals Living in Poverty 1 of 7 Rural Americans 923,400 Farmworkers 1.1 Million Homeless Persons

14 Indian Health Board Offers Primary Medical Care Dental Care Counseling and Support Services Transportation Health Programming centered in Patient Center Medical Care

15 Health Programming Patient Centered Medical Care with Care Coordination Services Diabetes Prevention Diabetes Management Preventative Health (SAGE, SCOPES) CVD Prevention Smoking Cessation

16 Indian Health Board Minneapolis Graphs showing people we serve In CY 2016, IHB served 4,927 patients and provided 21,578 encounters Who we see: Medicare 3% Poverty Level: Race: Medicaid 45% Uninsured 29% Private Insurance 23% Over 200% 2% % 7% Unknown 18% % 20% 100% and below 53% Hispanic 28% Caucasian 11% African American 15% American Indian/Alas kan Native 44% Asian 2%

17 Community Partnerships Minneapolis American Indian Center St. Paul American Indian Family Center Upper Midwest American Indian Center American Indian Family Center Division of Indian Work American Indian Cancer Foundation American Indian OIC Minnesota Indian Women s Resource Center Little Earth of United Tribes Minneapolis Chippewa Tribe Shakopee Mdewakantan Mille Lacs Band of Ojibwe Leech Lake Band of Ojibwe Boise Fort Urban Office Red Lake Embassy White Earth Urban Office Fon Du Lac Urban Office Women of Nations Anishinabe Academy Mashkiki Waakaaigan Women of Nations First Nations Recovery Indigenous People s Task Force Nay way yee (Center School) Kateri Residence Parents in Community Action Community Action of Minneapolis Pillsbury Waite House Children s Hospital of Minneapolis Medica Allina UCare City of Minneapolis University of Minnesota (Program for Health Disparities) Hennepin County Teen & Child Checks

18 ID Strat Tool Through the FUHN collaboration, we have access to claims data through the ID Strat Tool We use this data to help meet the triple aim: Reduce total cost of care, improve quality of care while increasing patient satisfaction

19 Care Coordination Workflow Once a month a new list is provided to IHB Patient list is divided between IHB s 4 care coordinators Filter by Treating Provider, Provider Most Seen, Short Name, Age Each CC gets their own list of pts to review that month

20 Care Coordination Mental Health, Substance Abuse Hannah, LADC, Chemical and Mental Health Coordinator Youth <18 years old Chelsea, RD, Youth and Family Diabetes Hilary, RD, CDE, Diabetes Educator All other patients Indi, RN, PHN, Clinical Care Coordinator

21 Referral specialist Checks for correctness Insurance Follows up to see if patient attends appointment or not Communicates this to providers and care coordinators

22 Case Consult Presented to the Medical Team Medical Providers, Nurses, Care Coordinators, Referral Specialist Shared information about ID/Strat Reviewed how it was divided amongst CC s Explained how Care Coordinators were using the tool Asked team how they wanted to know info from ID/Strat Tool

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24 Care Coordination Investigate why are they on the list, claims data, IHB chart information, PMP

25 Care Coordination Strategies o Get them into clinic Phone and letter, we re exploring texting options o Communication - Huddle with providers, share information regarding triggers/gaps in care o Aware of clinic schedule Scrub the schedule daily, huddle, be available at patient s appt. o Educate, educate, educate - During visit, assist w/care coordination needs, provide on-call information, chronic disease self management, connect to services o Follow Up attend referral appointments? Fill meds? New meds working? RTC in a timely manner

26 Documenting in the Chart After investigating the list and out reach we document the findings in the patient chart Example: Document attempted contact efforts via phone and letter. We also document gaps in care. Per ID Strat tool Multiple ED visits for asthma. Pt has insufficient long acting RX. Met with nurse and provider prior to patient s medical visit to notify them of patient s ED visits.

27 Case 1 American Indian female, 42 years old Rules fired for Avoidable admission Uncontrolled asthma ED visit for chronic pulmonary diseases Patient smokes This patient comes into clinic regularly, unrelated to asthma

28 Case 1, cont. Gap identified: ED visits for Asthma -8/1/16 *5/20/16-5/21/16 (inpatient admission) -5/1/16-3/9/16-3/8/16-2/24/16-12/27/15

29 Case 1, cont. Care Coordination: CC notified provider that patient had multiple ER visits for asthma. Action: Provider acted on this information and made a referral to a pulmonologist

30 Case 1, cont. Outcome: Patient attended referral, received long and short acting Rx Quit smoking Claims data and patient chart showing patient filling asthma medication appropriately Patient has not had an ED visit since 8/1/16 for asthma ED visit as of 3/16/17 for chest pain only, benign CC followed this case to see the patient through the referral appointment, clinic follow up, providing smoking cessation education and support, reviewed appropriate ED use.

31 Case 2 American Indian female, 47 years old Rules fired for - Avoidable admission - Frequent flier in ED - Admit for MH or SA in past 3 months

32 Case 2, cont. Care coordination- CC met with patient s mental health provider from C&S where patient is established in both psychiatry and psychology. Gap identified - patient was not comfortable with current PCP.

33 Case 2, cont. Action: C&S provider discussed PCP options with patient at next visit. Patient met CC, discussed goals and chose a new PCP. Outcome: Pt attends medical appts. with new PCP Pt reported satisfaction!

34 Case 3 African American male, 33 years old Rules fired for Asthma/COPD w Admit/ED & insufficient long acting RX ED visit for Chronic Pulmonary Diseases Patient smokes 2ppd Comes in sporadically, unrelated to asthma Uninsured

35 Case 3, cont. o Gap identified Asthma w/no long acting inhaler o ED visits for asthma -3/20/16-6/8/16-3/18/17-4/3/17

36 Case 3, cont. March 9, 2017 Pt prescribed long & short acting w/340b, advised to quit smoking No insurance Care coordination: provided inhaler and NRT education, pt navigator contact information 3/13/17 CC: F/U w/insurance& meds. Pt did not pick up meds or contact insurance Informed provider about insurance status, & inquired about inhaler sample for pt

37 Case 3, cont. Outcome: 3/13/17 Attended clinic appt, received inhaler sample met w/pt navigator completed insurance application, is now insured! Reduced smoking CC: followed this case to ensure patient successfully contacted patient navigator and received medications

38 Thank you! Connectivity. Equity. Health.