Institute for Healthcare Improvement Summit March 22, 2016 This presenter has nothing to disclose.

Transcription

1 C7: How Value Based Care Can Improve Community Health David J. Bailey, MD, MBA President & CEO, Nemours Children s Health System Institute for Healthcare Improvement Summit March 22, 2016 This presenter has nothing to disclose. Disclaimer The project described within was made possible by Grant Number 1C1CMS from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the independent evaluation contractor. 2 1

2 Session Objectives Explore the impact of prevention and population health approaches on the model of care in the transition from fee-forservice to value-based reimbursement models Illustrate how community-based approaches to chronic disease management in children may improve outcomes for children and expand the reach of clinicians Demonstrate the successful application of simultaneous improvement of care with associated reduction in cost of care through integrated model of population health Nemours/A. I. dupont Hospital for Children Wilmington, Del. 250 beds NEMOURS PATIENT CARE IN FIVE STATES 350,000 Patients/1.3 million annual encounters 3,800 Trainees annually (1600 medical residents, fellows, students) Over 600 Employed physicians More than 200 Researchers 50+ Pediatric care locations 22 Collaborating hospitals NEMOURS PREVENTION & POPULATION HEALTH 23 States impacting >1,000,000 children Childhood obesity Asthma management Reading readiness Nemours Children s Hospital Orlando, Fla. 137 beds NEMOURS CENTER FOR CHILDREN'S HEALTH MEDIA 55 Children's hospitals 250 Community hospitals 300,000,000 Site visits annually 2

3 Value Based Care in a Fee-for-Service World Is Value Based Care really around the corner? Zeke s Story Value-Based Care Better Health Better Health Care Lower Cost Simplified Triple Aim 5 Value Based Care in a Fee-for-Service World Nemours Pilot Choose chronic disease: asthma Integrate our standalone population health unit into our clinical work Active community/multi-sector approach Goals Rapid cycle quality improvement Population health improvement Innovation and accelerated transformation 6 3

4 Value Based Care in a Fee-for-Service World Challenge: Revenue Reduction in current payor model Optimizing Health Outcomes for Children CMMI Award: ACA Funded through the Center for Medicare and Medicaid Innovation 3-year award beginning July 1, 2012 $3.7 million Cooperative Agreement Self Monitoring and Evaluation: Nemours Thomas Jefferson University & University of Delaware NORC at the University of Chicago (INCOMPLETE) 7 Nemours Socio-Ecologic Model Black text: Targeted population Red text: Interventions 8 4

5 Changes in Our Practice Model--Asthma Pediatric Primary Care Practices NCQA accredited PCMHs Behavioral Health Integration Deployment of a Navigator Workforce (Community Health Workers) Deployment of Integrators (Community Health Liaisons)_ Optimize Use of Technology 9 Behavioral Health Integration Psychologists and social workers hired and integrated into the practice team Role Behavioral health management Adherence promotion Team building/integration Population-based interventions education/groups Consultations 10 5

6 Deployment of a Navigator Workforce Hired, trained and deployed Community Health Workers unlicensed Link between clinic and home Home environmental assessments Case management of non-medical issues/concerns Reinforcement of asthma education 11 Deployment of Integrators/Community Liaisons Community engagement and mobilization Link between clinic and community increase in connections to community resources Focus on upstream determinants of health Facilitated partnerships with key stakeholders (HUD, ALA, DPH, etc.) Facilitated practice team members engagement with community Developed and implemented community action plans 12 6

7 Optimize Use of Technology Establish Asthma Registry QI measures and tracking Individualized Asthma Action Plan Standardized evidence-based approach Control stops in EMR Student Health Collaborative Asthma Education: Electronic newsletter Texting Program Provider Training Modules in Nemours University 13 Examples of Policy, Systems and Environmental Change Strategies Through Engaging Community Resources/Partners Change to DE Medicaid drug formulary allowing metered dose inhalers Smoke-Free Wilmington Ordinance Impacts smoking in public spaces Reduced school bus idling 100% of Head Start childcare centers are asthmafriendly School Health Collaborative school nurses have access to EMR Healthy Homes and Integrated Pest Management 14 7

8 Nemours Preliminary Observations of Impact CMS and independent third party evaluation is in process, not complete and not reflected here Nearly 50% reduction in ER visits from baseline Significant reduction in hospitalization Significant reduction in the direct cost of care BUT the infrastructure and training costs for a new model of care were large Parents report decrease in school absence but cannot be quantified from the schools due to lack of absence classification 15 Looking Forward We believe this framework would serve well for most chronic conditions of childhood Potential future efficiencies: Seasoned supervision Streamlined and standardized training Leverage existing stakeholder relationships and IT infrastructure Greater incorporation of digital technologies: telehealth, remote monitoring, predictive analytics 16 8

9 Thank You Questions? David J. Bailey, MD, MBA Institute for Healthcare Improvement March 22, 2016 Findings to Date January 6, 2015 dings to Date January 6, 2015 Appendix 18 9

10 19 Better Health Care Overall Aim: Integrate medical care with communitybased, population health -with a focused intervention to improve health, improve health care, and reduce costs for children with asthma for A) Children receiving care at each of three Nemours primary care sites located in Wilmington, Seaford, and Dover; B) Children living in the surrounding communities as identified by the following ZIP codes: Wilmington (19801, 19802), Dover (19901, 19904), Seaford (19973 and 19956). Better Health Care By June 30, 2013: For population A: 1) Increase the % of children with asthma who are connected with a community resource for non-medical, health-related needs from 0% to greater than 50%. 2) Increase provision of directed educational and community resources from 0% to >75% of families identified as being at high risk for smoking exposure to the child. By June 30, 2015: For population A: 1) Improve the rate of flu counseling and /or vaccine from 25% to >75%. 2) Increase complete clinician adherence to evidencebased asthma guidelines from 0% to 100%, 3) For the state of Delaware: Increase the number of children reached by implemented policy, systems and environmental change strategies to support asthmarelated child well-being from baseline of 0 to 50,000. Primary Drivers: Enhancement of FCMH Deployment of Navigator Workforce Development of Integrator Practices Optimize use of Information Technology Secondary Drivers Develop a well coordinated, interdisciplinary model of care Provide case management of non-medical needs for high-need families Hire community health workers as part of practice teams Integrate community liaisons into practice teams Partner with community leaders to affect environmental changes Embed practice guidelines in Nemours EHR and provide feedback to clinicians to guide practice improvement Provide family-centered age appropriate electronic health communications 20 10

11 Better Health Better Health By December 31, 2012: For population A: 1) Reduce asthma admissions from a current rate of 0.7% to the lowest (good) national quartile: 0.1% (100 per 100,000) 2) Reduce Nemours asthma readmissions by half: from 2.8% to 1.4% 3) Reduce Nemours asthma-related ED visits by half: from 42% to 21% By June 30, 2013: For population A: Reduce the average number of school days missed by 25% for the school year as compared to the school year. By June 30, 2015: For population A and B: 1) Decrease asthma related ED use among pediatric patient 2) Decrease asthma related ED use among pediatric patients on Medicaid from 25% to 12.5% 3) Decrease asthma related hospitalizations among pediatric patients 4) 4) Decrease asthma related hospitalizations among pediatric patients on Medicaid from 0.3% to 0.15% Primary Drivers: Enhancement of FCMH Deployment of Navigator Workforce Development of Integrator Practices Optimize use of Information Technology Secondary Drivers Develop a well coordinated, interdisciplinary model of care Provide case management of non-medical needs for high-need families Hire community health workers as part of practice teams Integrate community liaisons into practice teams Partner with community leaders to affect environmental changes Embed practice guidelines in Nemours EHR and provide feedback to clinicians to guide practice improvement Provide family-centered age appropriate electronic health communications 21 Reduced Costs Overall Aim: Integrate medical care with community-based, population health -with a focused intervention to improve health, improve health care, and reduce costs for children with asthma for A) Children receiving care at each of three Nemours primary care sites located in Wilmington, Seaford, and Dover; B) Children living in the surrounding communities as identified by the following ZIP codes: Wilmington (19801, 19802), Dover (19901, 19904), Seaford (19973 and 19956). Reduced Costs For population A: Reduce overall cost of care for patients with asthma, including Medicaid beneficiaries from a baseline annual cost of $11,132,936 to: $10,020,458 by June 30, 2013; $8,519,668 by June 30, 2014; $6,389,751 by June 30, Primary Drivers Model Sustainability Secondary Drivers Track service utilization statewide through the Delaware Health Information Network Use Rapid Cycle Improvement strategies to make changes to the model Use data from this model to work with Delaware Medicaid and the Governor s Office to propose reimbursement strategies that would expand the model throughout Delaware 22 11