Leveraging Nurses in Health Transformation: Population Health and Care Management Models

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1 Leveraging Nurses in Health Transformation: Population Health and Care Management Models OCN Annual Conference Judy Tatman, MSHA, BSN, RN October 20,

2 Population Health & the Triple Quadruple Aim Caregiver Engagement 1

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4 The Cost Imperative Value based healthcare is becoming the expectation... CCOs Intel ACO Medicare Advantage, Medicaid, MACRA Value = Outcomes + Experience Costs 3

5 National Health Expenditures per Capita NHE as a Share of GDP 5.2% 7.2% 9.2% 12.5% 13.8% 14.5% 15.4% 15.9% 16.0% 16.1% 16.2% 16.4% 16.8% 17.9% 17.9% Notes: According to CMS, population is the U.S. Bureau of the Census resident-based population, less armed forces overseas. Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at (see Historical; NHE summary including share of GDP, CY ; file nhegdp10.zip).

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10 Distribution of National Health Expenditures (by Type of Service in Billions 2010) Nursing Care Facilities & Continuing Care Retirement Communities, $143.1 (5.5%) NHE Total Expenditures: $2,593.6 billion Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity, research, and structures and equipment, etc. Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at (see Historical; National Health Expenditures by type of service and source of funds, CY ; file nhe2010.zip).

11 Care Model The Challenge 6 most costly components of care identified (align initiatives in each category to effect overall health expenditures) 10

12 Percent of Total Health Care Spending Concentration of Health Care Spending in the U.S. Population, 2009 ( $51,951) ( $17,402) ( $9,570) ( $6,343) ( $4,586) ( $851) (<$851) Note: Dollar amounts in parentheses are the annual expenses per person in each percentile. Population is the civilian noninstitutionalized population, including those without any health care spending. Health care spending is total payments from all sources (including direct payments from individuals and families, private insurance, Medicare, Medicaid, and miscellaneous other sources) to hospitals, physicians, other providers (including dental care), and pharmacies; health insurance premiums are not included. Source: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey (MEPS), Household Component,

13 Caution: a unified approach is preferred 12

14 Patients as the organizing approach High risk patients: Clinic-based care managers; Proactive Outreach Team; Health Resilience Specialists; Elder at Home Rising-risk patients: Medical Home & Chronic disease management. Low-risk patients: Express Care, Wellness Promotion, Self-Care Advisory Board content 13

15 Strategy: Patient segmentation Evolve from numerous payer-specific pilots to organization wide commitment and investment Use a patient-centered model as we design our approach. 14

16 So where do we start? 1.Culture is Key 2.Define Organizational Infrastructure 3.Understand and address the gaps- STAY FOCUSED 4.Celebrate current successes 15

17 Culture is Key to Transformation 1. Keep the person served at the center 2. Mindset of stewardship 3. Professional pride of each team member and top of license practice 4. Open and honest communication between providers, clinicians, and other team members 16

18 Oregon Population Health infrastructure Population Health Council Focus on utilization Prioritize and provide oversight to current Pop Health initiatives Affordable Services Council Focus on unit cost Prioritize and provide Oversight to current Unit cost initiatives. Aligning the work of existing councils Care Management Integration Council Pharmacy Integration Council Population Health Backbone Trend Bender and Medical Economics 17

19 Transitions and Navigating the System Complex! 18

20 Care Management: Build Capacity and Competency Who needs help? Identify: individuals and groups Stratify/ Prioritize Who can we help? Measure/ Evaluate Intervene: operations and clinical Did we help? What kind of help? 19

21 Care Management Integration Council Care management leadership from PMG, inpatient, home & community services, PHP, and other settings Leads development of a Providence integrated model of care management and connected care experience Drives greater affordability and quality Works within Providence across care venues and with community partners Works across region and with system teams Buoys trusted patient-centered medical home team 1. Effective information flow 2. Coordinated, safe transitions CMIC Executive Team Judy Tatman, Executive Sponsor, Regional CNO Susan Abate, VP, PHP, Quality James Arp, Chief Exec, Home and Community Services Ann Kirby, Executive Director, CM Ben LeBlanc, MD, CMO, PMG CMIC Membership Judy Tatman, Executive Sponsor, Regional CNO Jane Brandes, Director, Hospice Julie Heimark, Mgr HH Intake/Business Development Ann Kirby, Executive Director CM Meg Linza, Director Care Management, PMG Nancy Trumbo, Reg. Director, Inpatient CM Amanda Purcell, Manager, Operations, ElderPlace Melissa Topp, Manager, QMM CM, PHP Bonnie Wilson, Reg. Director, Emergency Services 20

22 Care Management Integration Council Areas of Focus 1. Build capacity and competency 2. Develop infrastructure Gap analysis > filling the gaps Role definition and collaboration ROI calculation IT communication pathways Community resources 3. Develop interventions Aligning across all risk contracts Standardized risk assessment tools Interventions for high needs populations Transitions of care 21

23 Pushing on multiple levers simultaneously Examples of what we are working on: Setting prioritized list of key initiatives and aligning stakeholders Addressing high acuity patients care management Addressing low acuity patients Prov RN, Express Care, and Express Care Virtual (continuum of access) Enhancing behavioral health resources and services across the continuum Using data to prioritize interventions Tracking the data (CMIC dashboard as example) Investing in IT and HIE platforms Consistent longitudinal care plan across IT platforms Care management user groups Working with community partners to address non clinical factors in the care plan Reinforcing key transition points to get patients back to primary care Developing TCOC culture within the clinics 22

24 PMG Overview PMG Express Care Clinics Date opened Name Type Kruse Way Stand alone Interstate Stand alone Fishers Landing Walgreens Milwaukie Walgreens Raleigh Hills Walgreens Happy Valley Walgreens Salmon Creek Walgreens Gresham Powell Walgreens Pearl District Stand alone North Lombard Stand alone Glisan & 181 st Walgreens Hillsboro Walgreens Murrayhill Walgreens Bethany Walgreens See PMG Annual Report for more info Note that we have a separate reporting structure for Clinical Programs (cardiology, oncology, neurology, women s health, children s program, orthopedics, medicine, surgery, hospitalist) 14 Express Care Clinics 23

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26 Oregon Region: Comprehensive portfolio 1. Continued development of care model: leveraging assets of integrated delivery system; actively implementing and directing patients to lower cost settings of care; developing more effective pathways between contracting, data, and utilization 2. Population Health Council prioritized cross-continuum interventions Reduce Avoidable Low Acuity Admits Discharge Transition Support-including the Coleman Model/Pathways Optimizing care continuity for ED frequent visitors Reduce ED Boarding for Behavioral Health (BH) Patients Onboarding of new patients in risk-based products 3. Continued implementation and evaluation of new interventions Elder at Home Health Resilience Program Proactive Outreach Team New models for Home Health, Community workers, Pathways (Social Determinants) 4. Increased emphasis on utilization and lower cost site of service within business units based on PHP and new system ACO data resources 25

27 2016 prioritized Population Health initiatives 1. Reduce Avoidable low acuity admissions TIAs, 1 st Seizure, low risk CP, Cellulitis 2. Discharge Transition Support Coleman Model for high risk elderly patients 3. Optimize Care continuity for frequent ED utilizers Maximize Care Plan use in EDIE/Premanage 4. Reduce ED Boarding of BH patients Community MH care plan activation via employed and contracted BH navigators 5. Onboarding new patients Chart building risk stratification High risk patients to get PCP appt, care plans, case management 26

28 Celebrate successes : Case management programs for high risk population Proactive Outreach Team Team is ramping up. Currently 4 FTE (3 CM and 1 Pharmacist); adding 2 more this year Using Impact Pro and other predictive tools to target populations Health Resilience Program Contracted service with CareOregon, now bringing inhouse Program launch FTE in 6 clinics each with a case load of ~20 Clinics: North PDX, SE, Milwaukie, NE, Sunset, Cascade Elder at Home Program launch summer 2015 Core team of 24 FTE; 584 pts have opted in Increased Use of Predictive Modeling, Identifying Risk, and Improving Outcomes 27

29 Summary Most operational elements are in place for success in population health; opportunity to further develop and enhance effectiveness and work better across the continuum and in partnership with PHP/ACO teams We ll work across the continuum to further develop our model of care: this needs to include a new look at how Home Health is utilized differently, use of health coaches and community workers, and Pathways We ll strive for a single model of care in primary care rather the developing unique care management teams and resources based on contract requirements 28

30 Summary Cost imperative to be successful in Population Health We ll talk about interventions in terms of the patient segmentation pyramid Deliberate culture and infrastructure necessary Nursing plays a key role across the continuum and transformation process and will need to develop new competencies and skills We will get better at this over time 29

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