EpiCenter and Target Population Initiative. Better Health For All

Transcription

1 EpiCenter and Target Population Initiative Better Health For All

2 Background on the EpiCenter The Need: Large integrated health and hospital systems like the Santa Clara Valley Health and Hospital System are challenged by 1) too many competing priorities 2) disparate sources of data, and 3) limited analytic capacity. The Opportunity: Develop a center for population health improvement with strong analytic capability that can systematically and effectively link individual clinical health and community-level population health efforts. Staff Competencies: Project management, analytics, health planning, improvement science, epidemiology, research, business intelligence. 2

3 EpiCenter: Location in Organizational Structure Santa Clara Valley Health and Hospital System EpiCenter, Center for Population Health Improvement Valley Medical Center Valley Health Plan Behavioral Health (DADS & Mental Health) Custody Health Public Health

4 Population Health from a County Perspective

5 Segments of Santa Clara County Population Currently 12 high need patient projects including intensive case management of homeless patients High need patients: high cost/ high need At risk to become high need patients Approximately 300,000 unique patients Total Population: 2.0 million residents and visitors

6 Common Definition of High Need Patients 1. Have a cost of care that falls in the highest 10% of all SCVHHS patients; 2. Have co-occurring medical and behavioral health conditions requiring ongoing care from the SCVHHS system; and, 3. Have a utilization pattern that includes preventable, inappropriate or recurring use of high cost services such as: 1. Emergency Department 2. EMS 3. Emergency Psychiatric 4. Inpatient Psychiatric 5. Inpatient Hospital

7 EpiCenter Priorities for FY 15 Identify Target Populations Advanced Analytics and Data Infrastructure Improvements Population Health Initiatives Assist Ongoing Improvement Projects Improvement Infrastructure 7

8 Identify Target Populations Opportunity: Segmenting and identifying target populations will allow the HHS to understand its patient needs and conduct system-level population health improvements. Expected Results: Deeper understanding of our population Improved system-wide planning Cross-agency collaboration Data sharing Improved competitiveness and readiness for grant opportunities Timeline: Tool and first set of target populations (February 2014). Current Utilization Cost Future Utilization Likelihood to Improve Target Populations 8

9 Target Population Identification Planning Process Building the Foundation Meeting 1: Introductions and project background Meeting 2: Review of current cross system initiatives Developing the Framework Meeting 3: Review of interview data and existing frameworks Meeting 4: Review of quantitative data and populations Meeting 5: Tool development Refining the Tool Meeting 6: Initial review of tool Meeting 7: Tool finalization

10 Potential Populations and Interventions Everyone: Whole Person coordinated approach Geographic: Partnerships, environmental changes, social support At-risk: Targeted screening Disease-state: Registries and case management High Users: Intensive case management and/or permanent supportive housing

11 A Simultaneous HUMS Approach 1. While each agency within the HHS has several non-compatible databases our Epic EHR contains data on: 1. ED 2. EMS 3. Emergency psychiatric Services 4. Inpatient Psychiatric Services 5. Acute bed days 2. Using a point system we can identify high utilization of two systems 3. Cross reference these patients with our list of chronically homeless and frequent users of custody health 4. Study the highest users to and apply lessons to overall approach