Three Key Elements for Successful Population Health Management

Transcription

1 International Global Forum for Health Care Innovators RESEARCH BRIEFING Three Key Elements for Successful Population Health Management

2 QUESTIONS FOR HEALTH SYSTEM LEADERS What businesses should you be in? Who will your partners be? What is your role in the communities you serve?

3 Environmental forces are combining to cause major changes to our industry. The Baby Boomers are retiring and ageing, utilising more health care services. Information and data are increasingly available and portable. Chronic disease incidence is reaching epidemic proportions. And increasing global health reform has set a new timeline for change. Together, these forces are pushing providers past the point of incremental change towards a new business model centred on delivery of comprehensive care and management of total cost risk. Organisations on the transition path to population health management must prioritise three foundational elements: Information-powered clinical decision making Primary care-led clinical workforce Patient engagement and community integration Read on to learn about strategies progressive organisations are pursuing in each of these areas. Three Key Elements for Successful Population Health Management 1

4 Information-powered clinical decision making Use robust patient data sets to support proactive, comprehensive care Operate within an integrated data network Position a leader to merge data analytics with clinical care Primary care-led clinical workforce Elevate GP to CEO of care team Mobilise community workforce to extend care team reach Patient engagement and community integration Map services to population need Overcome non-clinical barriers to maximise health outcomes Integrate patient s values into the care plan Use community stakeholders to connect patients with high-value resources 2 Global Forum for Health Care Innovators

5 01 Information-powered clinical decision making Population health leaders need to focus on the data and information that will increasingly power clinical decisions. Today, global health care systems are starting to build towards a vision of complete data integration, getting the right systems in place to work with each other. While this is no small feat in itself, the next challenge will be leveraging data to redesign care. Health systems will need to be able to use IT systems to advance clinical outcomes, improve quality, and lower costs. Ultimately, to fully leverage your IT investments, you must be able to use the wealth of information at your disposal to deliver information-powered care to patients in real time. Three Key Elements for Successful Population Health Management 3

6 Use robust patient data sets to support proactive, comprehensive care If you re going to deliver information-powered care, you re going to need regular access to information about patients health status. How do you get more information from patients about what they re doing when they re outside the four walls of the doctor s office? Buurtzorg, a home care organisation in the Netherlands, connects quantitative data from a physical, behavioural, and social health assessment with qualitative data from home visits to develop and continuously update personalised care plans. During home visits, Buurtzorg nurses record patient behaviour, patient understanding of disease, ability to increase such understanding, and patient motivation to self-manage in their IT system. Buurtzorg s extensive data set, combined with real-time problem solving in patients homes, lays the foundation to identify interventions that work best for individual patients. And the more you know about an individual, the more you can create unique care plans to meet that patient s needs. The P4 Medicine Institute is a USbased collaboration between Ohio State University and the Institute for Systems Biology to track extensive sets of data related to patients total health. Each patient receives a customised diagnostic profile, including a physical exam and detailed biomarker analysis, which is the basis for an individual care plan. The plan is reinforced by real-time, ongoing biological screening and selfmanagement support. The disease-risk analysis may predict future issues, allowing doctors to engage patients in behavioural modifications and interventions to slow or even prevent the onset of diseases. 4 Global Forum for Health Care Innovators

7 P4 is mostly an aspiration today, but hospitals have come a long way in their ability to use data to direct care. Institutions will continue to move forward in two ways: 1 2 From thinking in terms of managing a population to using personalised information to create individually customised care plans From retrospective analysis to acting in real time to prevent adverse events Migrating Care Delivery Model to Offer Personal, Proactive Care Individual Health Profile Granularity of Data Population Molecular Activity Data Real-Time Clinical Data Disease Registry Biometric, Genetic Analysis Daily Home Monitoring Today Individual Retrospective Anticipatory Elapsed Time Ongoing access to and analysis of patient health information is the key to providing proactive, preventive care. Three Key Elements for Successful Population Health Management 5

8 Operate within an integrated data network To leverage data, you ll need an integrated network to allow information sharing across platforms within your organisation and across independent providers. Financial incentives for health information exchange (HIE) implementation have started to reshape the IT investment landscape across regions. In Germany, for example, a new law incentivises hospitals to send an electronic discharge letter to primary care. Advances like HIEs also signal the decline of data ownership as a differentiator among providers. As data access becomes universal, organisations will set themselves apart by what they do with that data. Position a leader to merge data analytics with clinical care While CIOs 1 continue to focus on building, refining, and maintaining the IT backbone, other leaders will need to figure out how to mine information from clinical and operational data, distill best practices, and create information-driven care plans. North Shore-Long Island Jewish Health System filled this need by creating the Chair of Population Health. Her team tracks the impact and results of pilot programmes, determining which have the greatest measurable impact and thus should be offered to local businesses and the community at large. Every organisation will need to differentiate its clinical services by leveraging and applying data analytics and find someone with the appropriate knowledge and credibility to lead the effort. 1) Chief information officers. 6 Global Forum for Health Care Innovators

9 02 Primary care-led clinical workforce Advances in information-driven care will have a profound impact on the clinical workforce. In a data-powered world, the critical skills of the workforce are those that connect most directly to the laying on of hands and motivating patients to achieve better outcomes. Next-generation technology will support providers in advancing clinical care to help establish high-quality, low-cost care pathways. Technology will also allow providers to extend the reach of the workforce. And within care management, technology will play a supporting role as general practitioners (GPs) manage larger clinical teams and patient populations to help improve overall population health. Three Key Elements for Successful Population Health Management 7

10 Elevate GP to CEO of care team When it comes to primary care, the critical issue for the future is shortage. The World Health Organisation estimates a current global shortage of 4.3 million health workers; many of them are in the primary care space. And we re unlikely to fill the primary care gap with doctors alone. Instead, hospitals and health systems will need to build comprehensive primary care teams, with the GP working as the team captain to manage care across a range of providers including nurses, social workers, and others. Prioritise Top-of-License Practice from Entire Team GP CEO of Care Team Team and operational manager; leadership decisions enable top-of-license practice Service oriented, strong interpersonal skills Financial, performance, and clinical information manager Traditional business competencies such as leadership, strategy, and delegation are key Care Team Care Managers Effective communication skills crucial Team work ethic enables top-of-license practice Strong critical thinking competencies Longitudinal and proactive patient care focus Able to coordinate, manage non-clinical personnel 8 Global Forum for Health Care Innovators

11 With this training and new team structure, how many patients can one GP care for? You can t increase patient volume too quickly GPs must first get comfortable with new competencies like team-based care and integrated technology but you will need to accommodate more primary care demand. Additionally, managing the transition requires removing barriers in current incentives to encourage doctor support of team-based care and managing population health. Dean Health System 1 in the US been actively converting primary care practices into medical homes 2 since 2004, equipping primary care sites with teams of clinicians working at the top of their licenses. Technology provides additional access and support to patients outside of the practice walls. And Dean aligns the compensation model to the goals of the medical home. This ensures doctors are rewarded for meeting the care management needs of patients. Productivity Measures on the Way Out, Quality Measures on the Way In GP Compensation 2006 GP Compensation Other 2% 20% Incentive Elements: Population health cohorts Productivity 98% Productivity 60% 55% Other 35% Sample Metrics: Patient IT utilisation 4 Efficient prescribing Patient satisfaction Quality GPs will need to be comfortable managing a team of clinicians, which means they will need training in team management. Incentives should be aligned to population health management goals. 1) Dean Health System was acquired by SSM Health Care in ) The medical home is a US term representing a team-based health care delivery model to provide comprehensive and multidisciplinary care to patients. 3) Total greater than 100%. 4) Percentage of patients active on the MyChart patient portal. Three Key Elements for Successful Population Health Management 9

12 Mobilise community workforce to extend care team reach The care team model likely also includes some new members specifically, non-clinical workers who can help patients navigate the health care system and peers who can provide ongoing coaching and support. In Canada, Ottawa Inner City Health (OICH) provides comprehensive health care to homeless patients in shelters. These care units are run by personal support workers, with the help of visiting nurses and doctors. Services cover a wide range from palliative to dental care. OICH has treated more than 3,600 chronically homeless individuals so far, ensuring their health outcomes are comparable to the Canadian standard. WellMed Medical Group in the U.S. has broadened its non-clinical workforce to include patient peers. Doctors select high-performing, well-managed diabetics who they think would be good mentors; the mentors participate in a four-day, 16-hour training course and then are matched with mentees identified by their doctors as needing additional self-management support. The programme not only drove improvements in mentees health status mentors benefited, as well. Percentage Increase in Blood Sugar Checks After Six Months of WellMed Medical Group Programme 32% 15% Mentors Mentees To improve patient activation, put someone on the team potentially a non-clinical peer whom the patient can call with questions or for additional guidance and support. 10 Global Forum for Health Care Innovators

13 03 Patient engagement and community integration The first two elements focus on competencies the health system needs to develop. The third element shifts the focus outward: how your system relates to patients and ultimately your community. What place do you want to occupy in the health care ecosystem? If health care is to become patientcentric, where do you need to be? The challenge of becoming a patient-centred enterprise is that people do not want to be patients; providers are outside of the sphere of their day-to-day activities. If you are going to partner with patients in managing their health and especially if you are going to be at financial risk for the health of those patients you must become integrated into patients daily lives. How far can, and should, the health system reach? You ll need to overcome non-clinical barriers to achieve the best outcomes, integrate patients values into the care plan, and communicate continuously with patients to address and bridge care gaps. Finally, you ll need to integrate community stakeholders who can connect patients with high-value resources, while expanding your reach beyond the clinical care continuum to anchor community health. Three Key Elements for Successful Population Health Management 11

14 Ellis Medicine Map services to population need Population managers must build connections across the entire care continuum. Ellis Medicine in New York, US, has become an exemplary health system with respect to matching service offerings to community need. The New York State Legislature created a commission to address statewide cost and utilisation issues. The commission analysed markets and determined that in Schenectady, New York, a tertiary care hospital, a women s hospital, and a hospital treating many of the city s underprivileged residents should be merged into a single community provider. The new health system leadership team used this mandate as a call to reevaluate community needs and match service offerings to those needs. Today, the unified system, known as Ellis Medicine, has an acute care hospital, with the two remaining facilities reenvisioned as a women s centre and a comprehensive medical home. The Ellis Medicine Medical Home provides not only outpatient medical services and robust primary care, but also dental care. Social and community services are integrated as well, creating a one-stop experience for all of the patient s health-related needs. For example, when community members come to the Ellis Medicine Medical Home, they also find a welcome centre for the school district. Ellis Medicine Medical Home (former inpatient facility) Customer Services/ Patient Advocate Family Health Centre Pediatric Health Centre Imaging Conf. Room Lab Chapel PAT 1 Health Services Navigators Wound Care/ Infusion Therapy Dental Health Centre Day Surgery Schenectady City School District Welcome Centre Emergency Services 1) Pre-admission testing. 12 Global Forum for Health Care Innovators

15 At the start of this transformation, Ellis s CEO approached two other community organisations delivering health or social services to build a truly seamless continuum of patient-centred care. Twenty-five community leaders meet quarterly to improve collaboration and reduce duplication among community offerings. The results: Visits to Ellis s medical home are rising quickly, thereby stemming Emergency Department (ED) utilisation at their hospital. SPOTLIGHT Number of Visits to Family Health Centre, Emergency Department 2,701 3,706 Family Health Centre 2,118 2,080 Emergency Department January 2009 October 2010 Strengthening options across the continuum of care can simultaneously improve utilisation patterns and better serve the community. Three Key Elements for Successful Population Health Management 13

16 Overcome non-clinical barriers to maximise health outcomes We know that a small minority of patients drive a disproportionate share of health care spending. For many of these patients, the greatest barrier to improving their health is not a clinical issue but a social or financial barrier. Massachusetts General Hospital joined an extensive government-run care management pilot programme to improve quality of care and reduce cost for 2,500 of their highest-risk fee-for-service chronic disease patients. The hospital assigned each patient to a comprehensive care team, which included a primary care doctor, an experienced nurse case manager, a social worker, and a pharmacist. They also hired a non-clinical community resource specialist to work with the care teams, focusing on the non-clinical factors that influence clinical outcomes. If transportation problems prevent a patient from getting to appointments or filling prescriptions, the community resource specialist who builds and maintains a database of community resources connects the patient to transportation resources. This approach allows clinical team members to operate at the top of their clinical licenses without having important non-clinical needs slip through the cracks. This intensive care management model has driven major improvements in outcomes and produced significant return on investment: ED visits, hospitalisations, and mortality rate have all declined, and the programme saved 2.65 USD for every dollar spent. 14 Global Forum for Health Care Innovators

17 Multilevel Team Allows Coverage of Clinical, Non-clinical Patient Needs Primary Care Doctor Exclusive clinical practice Time saved by team averages minutes per day Nurse Case Manager Responsible for 200 patients on average Nurse, 20+ years experience Primary contact for patient Community Resource Specialist Non-clinical background Handles non-clinical patient issues that interfere with clinical outcomes Additional Care Management Programme Team Members Social Worker Pharmacist Medical Director Patient Social Assistance Transportation arrangements Appointment reminders Community health resources Caregiver assistance Socialisation groups Friendly phone calls to isolated patients Resource Coordinator Compiles repository of community resources Forges relationships with local organisations Fields direct patient requests Non-clinical Home Services Durable medical equipment ordering Medical device replacement Home care services Meals on Wheels Acknowledging and addressing non clinical challenges outside of the normal primary care structure improves clinical outcomes, especially for the highest risk patients. Three Key Elements for Successful Population Health Management 15

18 Sutter Health Integrate patient s values into the care plan You must also consider your relationship with patients when they are faced with difficult, complex medical decision making. At no time is this more critical than when considering end-of-life care. Sutter Care at Home s Advanced Illness Management (AIM) programme provides both curative and comfort care within a patient s home, then transitions patients to hospice as needed or desired. The AIM care team comprises nurses and social workers, who manage the home care, and a doctor, who acts as a team consult. The doctor creates the care plan with extensive input from the patient and family. The care plan is structured around meeting patient goals. We believe in person-centred goals, Sutter Care at Home s CMO 1 notes. People want to be people, not be patients. A personal goal might be to sit at the dinner table every night with family. Clinical goals should emerge from and support these personal goals. The results are striking: acute care hospitalisations are way down, and hospice use is way up, leading to a 2,000 USD decrease in per-patient monthly costs for those enrolled in the programme. Patient and family satisfaction rates are up, as well proof that you can find real return in doing what is right for each patient. 1) Chief medical officer. Incorporating patient input and goals can improve care planning and outcomes. SPOTLIGHT 16 Global Forum for Health Care Innovators

19 SPOTLIGHT Use community stakeholders to connect patients with high-value resources To truly improve the health of your community, you need to think beyond the patients who are in your offices and hospitals today. You need to find those patients who are at risk and bring them into the system so that you can begin to manage their underlying problems before they become acute. To do this, you will need to integrate your organisation more deeply into communities and partner with those who have influence within them. The postal service in Jersey, an independent British island, saw a revenue opportunity in supporting their local health care providers to stem high health care resource allocations among the elderly. Their Call & Check initiative expands the role of postal workers to check on frail elderly patients, pick up and deliver their prescriptions, and give appointment reminders. The Silver Line, a befriending service in the UK, supports elderly individuals in need of physical and emotional support structures. Volunteers provide elderly patients with emotional support, as well as health and social care connections as needed, thereby preventing inappropriate ED utilisation. To identify patients at risk, Silver Line coordinators work in the ED of local hospitals and advertise their services in the community. Today, more than 2,000 calls are placed every day, and there s never a shortage of volunteers. It s not enough to treat the patients already in the system; to make a meaningful impact on community health, providers need to reach at-risk residents. Three Key Elements for Successful Population Health Management 17

20 CONCLUSION Future success will require a different playbook than the one health systems are operating with today. 18 Global Forum for Health Care Innovators

21 Are today s measures of success the same ones that will indicate strength in the future? You must think about building the assets, relationships, and skills that your system will need to thrive in a new environment. Not every country or individual organisation is on the same transition path; each serves its own population and patient needs. We ll likely see many different roads forward the challenge is figuring out which one is the right path for your organisation, the direction that best aligns your organisation s strengths with the needs of your community. Amid this change, health systems must maintain the heart of the business highquality patient care. No other institution is more integrated into the community or holds more responsibility for the health of those living in it. Improving health is at the core of the mission and if you successfully build the population health management enterprise, you ll continue to advance the value you provide to those patients who rely on you every day. Three Key Elements for Successful Population Health Management 19

22 About the Global Forum for Health Care Innovators The Global Forum provides expert guidance to our members as they transform themselves into large, integrated systems responsible for managing patients health across the entire care continuum. This publication is part of our larger research initiative on population health management. To learn more about the latest global market trends and strategies that pioneer organisations are using to transform the delivery of care, please visit us at: advisory.com/globalforum Relevant Resources The Population Health Enterprise Hospitals around the world face rising pressure to care for more complex patient populations, and the traditional care model is no longer financially sustainable. In this study, learn how to build a high-performance care management network. The State of Care Transformation This study defines what the care transformation movement is and how to think about it. It addresses the latest policy trends from around the global and empirical evidence on care integration effectiveness, and it outlines several successful population health management business models from the US, Spain, and Germany. The Population Health Job Description Library This is our best resource on types of leadership and care management positions we see emerging in today s market, as well as how they fit into the overall organisational structure of hospitals pursuing a transition to valuebased care Advisory Board All Rights Reserved advisory.com LEGAL CAVEAT Advisory Board is a division of The Advisory Board Company. Advisory Board has made efforts to verify the accuracy of the information it provides to members. This report relies on data obtained from many sources, however, and Advisory Board cannot guarantee the accuracy of the information provided or any analysis based thereon. In addition, Advisory Board is not in the business of giving legal, medical, accounting, or other professional advice, and its reports should not be construed as professional advice. In particular, members should not rely on any legal commentary in this report as a basis for action, or assume that any tactics described herein would be permitted by applicable law or appropriate for a given member s situation. Members are advised to consult with appropriate professionals concerning legal, medical, tax, or accounting issues, before implementing any of these tactics. Neither Advisory Board nor its officers, directors, trustees, employees, and agents shall be liable for any claims, liabilities, or expenses relating to (a) any errors or omissions in this report, whether caused by Advisory Board or any of its employees or agents, or sources or other third parties, (b) any recommendation or graded ranking by Advisory Board, or (c) failure of member and its employees and agents to abide by the terms set forth herein. 20 Global Forum for Health Care Innovators

23 Project Director Megan Clark Contributing Consultants Cabell Jonas, PhD Petra Esseling Executive Director Lisa Bielamowicz, MD Project Editor Amy Levin Designer Nate Smith Image Credit Cover: istock. Sources Commonwealth Fund, Home Care by Self-Governing Nursing Teams: The Netherlands Buurtzorg Model, publications/case-studies/2015/may/ home-care-nursing-teams-netherlands. Commonwealth Fund, Thinking Outside the Mailbox! commonwealthfund.org/interactivesanddata/infographics/2015/sep/ thinkingoutside-th box. MassGeneralCare Management Program, caremanagement/. Ottawa Inner City Health, ottawainnercityhealth.ca/home. P4 Medicine at Ohio State, osumc.edu/experts/. The Silver Line, org.uk/who-we-are/. ValentiK, A Hospital-Owned, Facility- Based Medical Home: Lessons from Ellis Medicine, presented at: The National Medical Home Summit, March 14, 2011, Philadelphia.

24 M Street NW Washington DC 20037, USA P F Third Floor, Melbourne House 46 Aldwych, London WC2B 4LL, UK P +44 (0) advisory.com