Panel Discussion: Home-Based Primary Care Led Population Management

Transcription

1 Panel Discussion: Home-Based Primary Care Led Population Management Moderator: Steven Merhan, MD Panelists: Barbara Sutton, MSN APRN ACHPN Terri Hobbs Christopher Day, MPH MBA

2 Faculty Disclosures Day Kindred House Calls Employee and Stock Holder Hobbs no relevant disclosures Merhan US Medical Management - Employee Sutton no relevant disclosures

3 Objectives Use the information presented to help them improve their home-based care services. Describe how home-based primary care can assist with population management.

4 Population Health Steve Merhan, MD Chief Medical Officer US Medical Management

5 Population Health Management is a transformational approach to healthcare delivery that shifts the focus from caring for patients who self-select for care based on their own assessment of their condition to taking transcendent responsibility for the health status of a cohort or population of patients Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder

6 For population management, success is more than a full schedule and busy switchboard Patients who do NOT come in for care may be as important to consider as those in the waiting room.

7 What are the Goals for Population Management? To manage variables in order to deliver or add value, where value is the maximum benefit for least cost Value is audience specific: Patient Improved quality of care and quality of health Provider Revitalized professional identity and compensation Payer Efficiency and appropriate resource utilization

8 How Do We Operationalize the Triple Aim? Population Health Management is a clinical operating model for systemsbased practice that operationalizes the Triple Aim Accountable Care is a payment methodology that can be achieved using Population Health Management.

9 Implementing Population Health Management requires mastering a separate and distinct operating model from traditional care delivery, including a specialized infrastructure with its own functional requirements and an associated set of operating capabilities Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder

10 Three Interrelated Tiers Drive the Operation of Successful Systems Tier One MEET FUNCTIONAL REQUIREMENTS Tier Two MASTER OPERATING CAPABILITIES Tier Three OPTIMIZE INTERACTION DESIGN 2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder

11 Example: Driving Tier One FUNCTIONAL REQUIREMENTS Power train Acceleration (fuel control and transmission) Deceleration (braking and transmission) Steering (directional management) Tier Two OPERATING CAPABILITIES Car: Use of the gas and brake pedals and steering wheel; gear shift/clutch Motorcycle: Use of the twist grip, hand and foot brake and foot gear shift Tier Three INTERACTION DESIGN Integrating the operational capabilities and following the rules of the road while driving with other vehicles 2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder

12 Functional Requirements of a Population Management Infrastructure Clinical, Claims, PDD, Financial, Operational, Consumer Rules for Sorting & Categorizing Data System-Level Goals & Program Eligibility Inputs Communication & Activation Strategy Person-Level Goals, Shared Decision Making, & Coordination Resource Allocation & Standing Orders Programs & Services Data Analytics /Reporting Population Surveillance Segmentation & Targeting Outreach & Engagement Care Planning Clinical Strategy Resource Managed Care Delivery Care Coordination / Collaboration Generated Data The Functional Requirements of a Population Management Infrastructure: Systems Elements and Interaction Design 2014 Steven Merahn, MD All Rights Reserved All functional requirements must be fulfilled; however, different organizations may fulfill them differently with various configurations of programs, platforms, partners and personnel

13 How Is Value Really Created? Via the Essential Triad: Care Planning Continuity Collaboration

14 Population Health Management Requires Two-Level Care Plan Development PERSON-LEVEL GOALS SYSTEM-LEVEL GOALS Reduce patientspecific risk factors Improve or stabilize condition-specific health status Improve or stability quality of life Increase affinity and loyalty of patients and families Person- Level Goals System- Level Goals Reduce ED Utilization Reduce All-Cause Hospitalization Reduce SNF Utilization Reduce Readmission Rates Patient Satisfaction Scores ACO Measures IAH Measures HEDIS Measures 2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder

15 While Quality Measures may be evidence-based, they are, on their own, insufficient to improve health status Improving health status or shifting patterns of resource utilization requires management of variables beyond QMs QMs Other EBP Other risks/conditions Patient engagement/satisfaction Life Life Life Life

16 Why Continuity Matters Right Brain Trumps Left Brain In Relationships Products and Services Primary Care Specialists Surgical Care Imaging Lab Tactical Performance Efficiency Consistency Availability Reliability Responsiveness Convenience Channels Medical Home Ambulatory inpatient Dignity Home care Authenticity Websites/App Integrity Empathy Sincerity Urgency Emotive Performance Affinity and Loyalty Are Built Through Experience

17 Continuity is critical because when providers and patients remain present in each others lives (even when they are absent from the daily schedule) the influence of the relationship extends beyond the immediate encounter.

18 Collaboration = Goal Achievement Collaboration is a mutually beneficial relationship between individuals or organizations who work toward common goals by sharing responsibility, authority and accountability for achieving results. 18

19 Home-based primary care is an extraordinary example of achievementoriented care delivery

20 Finally, lets not forget that improving the health status of individuals and populations fundamentally remains a human endeavor Thank You

21 Barbara Sutton, MSN APRN ACHPN Amita Healthcare

22 What is Population Health? Health care practitioners using similar treatment recommendations or guidelines for populations with a specific disease, injury or illness. Example: APRN & LCSW visits post hospitalization. Guidelines for each visit include medications, weights, diet. Visit frequency developed to maximize engagement and education.

23 Use of Best Practice Guidelines Elevate care management from art to science. Develop a unified approach to care management, bringing together patient data, provider data, and payer data. APRNs work closely with Heart Failure Clinic Ensure correct medications Exercise Weights and interventions

24 Engaging patients 99% of patient activity is not happening in the office, clinic or office: It happens at home! What is important to that patient? Their family?

25 Equity Patient subgroups can be defined by race or ethnicity, socioeconomic status, gender or geography. Eliminate inequalities deciding on treatment based on the overall health of the community, regardless of any one person s subgroup status.

26 Value for Employers Employers want employees to return to work sooner, and they want predictability in their total spending on healthcare. right care based on the evidence right time, right setting prompt access to care right price control the cost of care best life return to function and productivity best outcome patient satisfaction

27 Managing Costs Develop a continuum of partners Post discharge costs may exceed 50% of the total health care cost

28 Collaborating Develop relationships with Discharge planners, skilled nursing facilities, and home health agencies Reach out to develop community partnerships with senior services, housing agencies, transportation services, medication assistance programs.

29 Consider the broad determinants of health Health determinants include income and social status, social support networks, education, employment and working conditions, biology and genetic endowment, physical environment, personal health practices and coping skills, and health services.

30 Prevention Prevention - to prevent an event or to minimize its effect after it has occurred. Not every event is preventable, but every event does have a preventable component. Whenever possible, population-based practice emphasize primary prevention. Reduce hospital readmissions within 30 days

31 Collaborate Consolidate care management resources for high-risk patients. Care management works when the appropriate resources are brought together for these complex, high-cost patients.

32 References Williams, C A, & Highriter ME. Community health nursing: population focus and evaluation. Public Health Reviews. 1978, 7 (3-4): Turnock, B. Public Health: What It Is and How It Works. Gaithersburg, MD: Aspen Publishers, Inc., The Leading Lights Summit

33 Contract Negotiations Terri Hobbs, Executive Director

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35 Population Current census over 1,450 homebound adults 500 patients from two payers = $700,000 in additional revenue Work force support $180, % enrolled in Med Advantage 35% are receiving additional stipends 15% of our patients on IAH (Medicare ffs) Over $1 million IAH shared savings Yr 1

36 Payers we approached Payer 1 Medicare/Medicaid Contractor FFS plus $100 stipend Nurse Practitioner 1 year Payer 2 Medicare Advantage plan FFS plus $150 stipend Palliative care contract Payer 3 Medicare Advantage plan PMPM cap no risk Payer 4 In negotiations

37 Provide Actual Data

38 Expenses vs Revenue Expenses Revenue 50% 26% 19% 4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Expenses Fee for Service IAH Stipend MU Bonus

39 Key Points Get in front of the right person Prepare quality & patient outcome data Highlight the teams and functions Quality MU, PCPCH, PQRS & IAH Community partnerships and collaboration Polite persistence

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41 The Kindred Story Christopher Day, MPH MBA

42 Concentration of Risk and $ in U.S. Healthcare

43 A Higher Number of Chronic Conditions Predicts Utilization and Spending Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions Source: Chronic Conditions Among Medicare Beneficiaries, Chartbook: 2012

44 Exploding Number of Advanced Elderly with Functional Debility --> Growing Need for HBPC

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49 Gap in Health Care Delivery System: Creating a Solution for Elderly High Utilizers Medicare Eligible Years Current System Chronic Disease 2-20 Years Gap In Care Delivery In Hospital Death or Hospice <6 months Tier 3A Patients Home- Based Primary Care Chronic Disease 2-20 Years Medicare Eligible Years In Hospital Death or Hospice <6 months Tier 3A Patients 49

50 The Case of Virginia Virginia is 85 years old, a typical Tier 3A patient with the following demographics: End Stage (Stage IV) Congestive Heart Failure (CHF) Other Chronic Diseases COPD Diabetes DJD CKD Mild Dementia A life expectancy of < 24 months Virginia lives in an independent senior apartment with ~2 hours private duty/day Her adult children all live in other states

51 Population Served: Snapshot Elderly, homelimited Mean Age 86 74% Female Average of 20 Diagnoses Average of 7 Chronic Conditions Estimated annual cost > $32,000 per patient

52 Home-Based Primary Care Led Care Management OUTCOMES Improved Quality and Patient Satisfaction Reducing Hospital Readmissions Lower Cost for an Episode of Care

53 Home-Based Primary Care Practice Standards Comprehensive Care Staff Structure and Teams Improve Patient Experience Access to In- Home Care Improve Health Cost effective care Medical and Psychosocial Issues Management

54 Operational Approach to HBPC Led Population Health Management Hospital Home or ALF/ILF Home Care Tier 3A HBPC Practitioner Care Coordinator SNF Analytics Remote Monitoring Electronic record Foundation of Care Management Hospice

55 Population Health Outcomes Measurement

56 Quality Dashboards Ability to monitor/manage the performance of each Care Team by analyzing reports available on the Community Analytics Portal

57 Conclusions: Advantages of Home-Based Primary Care Led Population Health Management Home-Based Primary Care + Post Acute + Care Management Programs can provide a fully Integrated, Comprehensive Care Solution for the Rapidly Growing Elderly in the U.S. Preferred Place of Service Care where it s needed and wanted the most Continuum Fit Aligns with the health care Continuum, especially home health, hospice and rehab Quality /Cost Outcomes High quality, low readmissions improved outcomes, longer home LOS at a lower total cost Vehicle for At- Risk Contracting Proven contract model with willing managed care partners Senior Community Innovation Model can provide a platform for best practices and future growth Care Management Hub Vehicle for population health and care redesign 57

58 Panel Discussion Go to: 2Shoesapp.com/AAHCM Click on the session you are in 2. Ask and vote on questions