From Reactive to Proactive: Creating a Population Management Platform

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1 Session D9 / E9 From Reactive to Proactive: Creating a Population Management Platform Richard Gitomer, MD Director, Brigham and Women s Primary Care Center of Excellence Vice Chair, Primary Care, Dept. of Medicine Kristie Koch Director of Value Management April 22, 2017 These presenters have nothing to disclose.

2 Learning Objectives Describe a general paradigm for population management. Identify successful implementation of population management interventions. List strategies for transforming population management interventions in a foreign context to ones that respects local constraints. Formulate plans for implementation of successful population management interventions in the participant s local context. emoryhealthcare.org 2

3 Setting the Context * Source: (right)based on CPS ASEC , Kaiser/HRET , CMS OACT

4 4 emoryhealthcare.org

5 Using Payment Models to Improve Value A Blunt Instrument Reward or Performance Accountability for Value System Transformation Provider & Payer Capitation System Redesign Shared Savings Fee for Service Pay for Performance Bundled Payments Team Redesign Individual Effort Risk 5

6 Population management POPULATION HEALTH THE TRIPLE AIM the health outcomes of a group of individuals, including the distribution of such outcomes within the group. David Kindig improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations. Health Aff May 2008 vol. 27 no POPULATION MANAGEMENT The design, delivery, coordination, and payment of services for a defined group of people to achieve specified cost, quality and health outcomes for that group of people. David Kindig David Kindig, MD, PhD Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health the University of Wisconsin-Madison 6

7 Shift to Value Based Care PRESENT VOLUME x PRICE Fee-For-Service Success measured by maximizing volumes and revenues Fragmented care delivery Little standardization around clinical evidence and widespread quality and cost variation 1 Identify improvement opportunities across the continuum of care and adjust clinical workflows 2 Engage the right physicians in the right behavior change 3 Prioritize the right patients for the right clinical interventions 4 Align reimbursement incentives across the system FUTURE Value-Based Success measured by population health outcomes and total costs of care Integrated care delivery, treatment pathways Consistency with evidence-based care and utilization practices 7

8 Engagement & Wellness Care Plans The New Work Hi Risk 5% Rising-Risk 20% At-Risk 40% Healthy Patients 35% Advisory Board Patient Risk Paradigm Care Coordination Care Plan Execution Patient Engagement Acute & Chronic Conditions Medically Vulnerable & Clinically Complex Care Coordination Care Plan Failures Registry Outreach 8

9 POPULATION MANAGEMENT AT EMORY HEALTHCARE NETWORK 9

10 Emory Healthcare Network Shared Savings Attributed Lives 2017 Commercial 55K Lives Medicare Advantage 10K Lives Private Practice PCP Employed PCP Total EHN PCP 117 PCPs 129 PCPs 246 PCPs Primary Care Sites 43 Primary Care Sites 123 Primary Care Sites

11 Gap Closure in the EHN Managed by Primary Care Practices with existing staff PCMH v. Non-PCMH Employed v. Private VARIATION IN PROCESSES Day to Day: Pre-visit Planning: Manual, varied processes and frequency Point of Care: in EMR, only clinical data Periodic: Registry Review: Data Warehouse reports (Employed), EMR Reports (Private) Portal messages or mail merge 11

12 Gap Closure in the EHN Data & Tools from Central EHN to Support Monthly: PCP Reports with Gaps in Care Quarterly: Top Priority Measures Semi-Annual: Outreach to outliers Annual: End of year push for priority measures. Practices Manage with support for gap closure from Central Care Coordination. Healthy Start Visits for Medicare Advantage Implementation of New Tools: Disease Registry Decision Support Tool (Clinical & Claims data) Resolution of Systemic issues Diabetic Eye Exams 2016 Q2 Top Opportunity Measures Breast Cancer Screening Cervical Cancer Screening Diabetes Retinal Eye Exam 12

13 Care Coordination in the EHN Centralized Care Coordination Team 8-Member Multidisciplinary Team Tracking top 3.5% of Commercial Risk Contracts - High Risk - High Cost - Inpatient Discharges - ED Discharges Standardized algorithms & Workflows Predict the Risk Risk Stratify the Population Proactive Outreach & Engagement 13

14 Care Coordination in the EHN EHN Advantage: Caremore Collaboration for Medicare Advantage Embedded Care Coordination in Employed PCMH Practices 11 NCQA Level III Patient Centered Medical Homes (9 completed EHN PCMH Training program 2016) Need additional resources to support PCMH work FY17 Goal: RN Care Coordinator for each PCMH Practice 4 hired as of March % time: Annual wellness visits 50% time: Care Coordination Role still developing Care plans for high risk pts 14

15 POPULATION MANAGEMENT AT BRIGHAM AND WOMEN S HOSPITAL 15

16 Brigham Health COMPONENTS Brigham & Women s Hospital Brigham & Women s Faulkner Hospital Brigham & Women s Physician Organization STATISTICS Hospital Beds: 955 Physicians: 1,200 Outpatient Clinics: 150 Ambulatory Visits: 4.2 MM/Yr. Admissions: 46,000 IP stays PRIMARY CARE Providers: 216 (MD-180 & APC-36) Sites: 16 Attributed Lives: 153,496 risk) Value Contracts 3 commercial Medicare Shared Savings Medicaid ACO 16

17 Standard Work Flow for Gap Closure Serial processes enhance reliability POC Decision Support Pre-Visit Planning Registry Outreach 17

18 Standard Work Flow for Gap Closure Serial processes enhance reliability Assume 100 opportunities Process Reliability = 80% 3 successes 1 failure Pre-Visit Planning POC Decision Support Total Reliability 99 successes 1 failure Process Reliability = 80% 16 successes 4 failures Process Reliability = 80% 80 successes 20 failures Registry Outreach 18

19 Gap Brigham Health CENTRAL POPULATION MANAGER ~ 1 Population Health Manager (PHM) per practice Utilizes registry function in EMR Obtains outside test results Schedules colonoscopies Pend lab orders Generates list of patients needing appointments to close gaps Meet weekly with practice to review performance and obtain clarification Registry Management (Reliable Care Plan Execution) POC Decision Support Pre-Visit Planning Registry Outreach 19

20 Brigham Health Performance (all patients) 2015 New EMR Faulty Registry 2016 Reliable Data 7/

21 Care Brigham Health THE CARE MANAGEMENT FOR HIGH COST BENEFICIARIES DEMONSTRATION PROJECT 1 Brigham Health participation from Hospitalizations: 20% lower than comparison group ED Utilization: 13% lower than comparison group Annual Mortality: 16% vs. 20% in comparison group ROI: $2.65 reduction in medical cost for every $1 spent Since 2012: 3,700 enrollees from 9,500 patients screened 1 McCall, Nancy, Jerry Cromwell, and Carol Urato. Evaluation Of Medicare Care Management For High Cost Beneficiaries (CMHCB) Demonstration: Massachusetts General Hospital And Massachusetts General Physicians Organization (MGH) Web. 26 Mar

22 Integrated Care Management Program Care Coordination (Oversight of vulnerable populations) Risk Stratification Care Plan Development Care Plan Execution Structured Oversight icmp 1 RN/200 patients 16 RNs in the program + 1 CHF RN + 1 ESRD RN At-risk patients only (60%-70% of total Brigham PCP panel) Patient selection: Claims-based prospective analytics Collaborative care plan in collaboration with PCP Structured follow-up by icmp nurse Flag in EMR indicating patient has icmp nurse 22

23 EMBEDDED BEHAVIORAL HEALTH 23

24 Collaborative Care University of Washington PHQ-2 Vital Sign PHQ-2 >= 2 PHQ-9 BHCM Follow-Up Monitor PHQ-9 Develop Rx Plan Progress? NO Engage Psych PHQ-9 >= 5 Cont. PCP F/U Behavioral Health Care Manager Counselor, CSW, psychologist, or psychiatric nurse 24

25 Collaborative Care Brigham Health PHQ-2 Vital Sign PHQ-2 >= 2 PHQ-9 BHCM Follow-Up Develop Rx Plan PHQ-9 >= 5 Monitor PHQ-9 Progress? NO Engage SS or Psych Cont. PCP F/U Behavioral Health Care Manager Population Health Manager trained in behavioral activation and motivational interviewing (Bachelors degree also managing gap closure) Collaborative Care Agreement Defines roles, responsibilities, and expectations for psychiatry and primary care 25

26 26 MAKING THIS RELEVANT

27 Making All of This Relevant - Context Everyone s context is different Available resources Electronic support (EHR, disease registry, analytics) Market factors (proportion of population in value-based contract) Personnel issues Specific staffing and workflows tend not to generalize Principles do generalize emoryhealthcare.org 27

28 Making All of This Relevant - Strategies Make adjustments for your local context Reduce the scale Population segment examples Patients in risk contracts, certain zip codes (surrogate for high social needs), or an absolute number (based on resources available) Reduce the scope Population segment examples Limit to specific conditions (e.g. diabetes) Limit so specific interventions (e.g. BP control and not A1c in diabetics) Central vs. local Adjust scale and scope as context and resources change emoryhealthcare.org 28

29 Examples of Context & Strategies 29

30 Adjustments as Context Changes Current State: FFS Primary Care (Plus add on PHM Programs) Phase I Redesign: FFS Population Health Primary Care Phase II Redesign: Fully Integrated Primary Care Population Health Platform PCMH CPM* Medicaid ACO * PCMH Primary Care Care Teams ** BH* icmp* CPM* Medicaid ACO * Primary Care Care Teams ** icmp* BH* BH CPM icmp Care Team 196k 160k patients FY20 Medicaid ACO PCMH Time and Redesign Implementation * Currently funded to cover only a portion of our risk lives (right now about 90k patients or about 56% of primary care s covered lives). ** Currently taking care of approximately 160K covered lives across primary care. 30

31 Assignment Individually or in teams Consider an intervention that you want to implement at home Consider how you would change scale, scope, or both to fit your local context Describe the structure that you will create Complete the PDSA template for your first test of change Debrief in minutes 31

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