Introducing Population Health: Visualize the opportunity like never before and seize it June 29, 2018 Shirley Garcia, Director Product Management Dr. Todd Clark, Physician Solutions Specialist
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Introducing Population Health: Visualize the opportunity like never before and seize it Executive Summary Key Issues This presentation will help you Issue/Challenge As practices transition to value-based care, the ability to identify then effectively and efficiently manage patient populations are important to practice success Delaying or avoiding disease progression across the population Controlling medical costs and utilization Enhance care quality with dashboards that highlight care gaps for focused and targeted care initiatives Increase provider efficiency by leveraging the care team and aligning patient data with evidence based guidelines at the point of care Strengthen financial performance by identifying hidden risk and care opportunities, reducing unwarranted variation in care and costs Key outcomes impacted: Avoidable ED visits and hospitalizations Total medical expense Care gaps Health outcomes Overall patient experience June 29, 2018 3
Introducing Population Health: Visualize the opportunity like never before and seize it Agenda The importance of population health Population health management team and challenges faced GE Healthcare s Ambulatory Population Health module can help you more efficiently deliver informed care Stratify populations for intervention Coordinate care team activity Deliver evidence-based care Summary and Q&A Presenters. Shirley Garcia Director Product Management Dr Todd Clark Physician Solutions Specialist Any descriptions of future functionality do not constitute a commitment to provide specific functionality. Availability is subject to change. June 25, 2018 4
Why care about population health?
EXPENSIVE: HEALTHCARE COSTS PER CAPITA $8,000 $6,000 $4,000 $2,000 Source: Peter G. Peterson Foundation, Accessed 2016.
Quality
Population Health The Triple Aim - defines three inter-dependent aspects:* Improving the health of a population Improving the patients experience of care Reducing the per capita costs of care for populations The Quadruple AIM** Improving the work life of health care providers **Don Berwick, Health Affairs The Triple Aim: Care, Health and Cost, May 2008, vol. 27 ** National Association of Community Health Centers August 2016 : Adds improving the work life of health care providers, including clinicians and staff.
Population health management team and challenges faced
Primary Care Providers are the drivers of Population Health efforts Primary care physicians, who are on the frontlines of care, will be required to think differently. Doctors must take the lead in shifting their attention away from being an individual provider to a team leader in a care coordination model that demands they follow their patients more closely, glean patient data with an investigative eye and analyze that data to look for intervention opportunities when the evidence reveals patients health is declining. Medical Economics, November 28, 2016 by Nicole Lewis
New roles making their way into ambulatory organizations I m a Quality Director, help me to see benchmarks on clinical quality and other performance measures measure care access trends over time generate periodic reports measuring performance manage multiple measure sets including HEDIS, MIPS, UDS and others I m a Care Manager, help me see care gaps for scheduled patients today focus my outreach efforts identify patient attribution challenges identify cohorts of patients for outreach identify trends in care delivery across clinical areas I m a Care Coordinator, help me. with a Patient scorecard with gaps in care through automated reminders create entries available to broader team track outreach notify me of Hospital/ED, ADT keep patients engaged in their care. 11
Existing roles have new requirements I m a Quality Director, help me to see benchmarks on clinical quality and other performance measures measure care access trends over time generate periodic reports measuring performance manage multiple measure sets including HEDIS, MIPS, UDS and others I m a Provider, help me understand quickly, my patient s current care status help me see the complete picture of my patient s care even outside our walls specify actions to my care team based on gaps in care align my care with best practice clinical guidelines and align guidelines to our practice model I m a Healthcare Executive, help me understand the impact our providers make on total cost of care see service utilization trends by center/location understand risk scores for attributed populations measure care access trends work with teams to arrange the most cost-effective care.
GE Healthcare s Ambulatory Population Health module can help you more efficiently deliver informed care
More Efficiently Deliver informed care Stratify Populations For Intervention Coordinate Care Team Activity Deliver Evidence- Based Care Enable Quality Insights Deep EHR Integration Required for Success
Why adopt GE Healthcare s population health solution? Only Population Health Management vendor: over 400 curated and codified evidence-based guidelines inform decision making pre-configured with real-time bidirectional integration with GE Healthcare Centricity platforms intelligent patient-specific care plan automatically generated for the entire population Platform helps optimize revenue under both fee-for-service and VBC payment models workflows deliver proven clinical and financial outcomes Team-based care design helps ensure all team members practice at top of license reduces physician burn-out reduces variation in care
Stratify Populations for Intervention Patient Outreach Care Coordinator Scheduling Check-In / Registration Patient Front Desk The Encounter Nurse Provider Billing Performance Review Back Office Quality Director Platform Administration & Collaboration Hub IT Administrator
Meet Mark Stanze Quality Director Mark monitors physician Mark monitors grant measurement physician grant performance measurement to performance ensure financial, operational to ensure and strategic financial, objectives operational are and being strategic satisfied, objectives and is the are primary point of being contact satisfied, for answering primary questions point of contact about physician for answering analytics and reporting issues questions and interpretations. about physician analytics and reporting issues and interpretations. Mark coordinates the clinic s contractual and regulatory reporting efforts. Mark coordinates the clinic s contractual and regulatory He is very concerned about the meeting the contract targets and the reporting efforts. He is very concerned about meeting the potential financial impact. contract targets and the potential financial impact. Monitoring performance against contracts is only a part of my very busy day. I worry about missing a critical indicator impacting our revenue. I can't afford the time to dig for the details.
Identify Patient Cohorts Stratify patient populations to identify high-risk patients in need of care. Identify High-Risk Patients Prioritize Patients with Open Gaps Save and Share Patient Cohorts
Coordinate care team activity Patient Outreach Scheduling Check-In / Registration Care Coordinator Patient Front Desk The Encounter Nurse Provider Billing Performance Review Back Office Quality Director Platform Administration & Collaboration Hub IT Administrator
Meet Lynn Care Coordinator Lynn works collaboratively with Providers and staff to identify and support patients with chronic conditions, having complex needs, and reduces gaps in care as defined by the practice. Lynn facilitates communication, coordinates services, addresses barriers, and promotes effective patient education and self-management. I help our 15 Providers and the care team be efficient with their time. Dashboards help me identify and prioritize activities so I can focus on a patient s gaps in care, and care plans integrated directly into the patient s health record help me coordinate care.
Coordinate and Manage Care Prioritize and coordinate care team activities to optimize value. Run Quality & Productivity Programs Support/Standardize Care Delivery/Collaboration Common Care Plan
The care team is acting in concert to achieve quality performance measures Assign programs Standardize workflows Aligns skills and resources
Deliver evidence-based care Patient Outreach Care Coordinator Scheduling Check-In / Registration The Encounter Patient Front Desk Provider Clinician Billing Performance Review Back Office Quality Director Platform Administration & Collaboration Hub IT Administrator
Meet Dr. Harriet Winston - Physician Dr. Winston is a 45-year-old general physician who has built a successful independent practice. Dr. Winston s day is about finding balance between spending enough time with each patient and attending to the wide variety of needs for each patient seen. I want to take as much time as necessary with every patient, but I feel like all I do is stare at the computer screen to try and capture all the data I have to provide.
Deliver Evidence-Based Care Promote adoption of best clinical practices and support consistent, high-quality clinical decisions with the latest evidence-based guidelines at the point of care. Show Care Gaps & Opportunities Act on the Data Engage Patients
Help improve outcomes with decisions informed by evidence Proactive evidencebased medicine Individualize care plans Enhance patient health
Focus and Simplicity for the Care Team
GE Healthcare is committed to your success in value-based care Increase Provider Efficiency Population Health Analytics Patient Engagement Care Delivery Financial Management Enhance Care Quality Strengthen Financial Performance
Roadmap Available Today Incubation < 6 months On the Horizon > 12 months Cloud based integrated Care Management Platform Over 400 curated and codified evidencebased guidelines inform decision making Intelligent Patient-specific Care Plan automatically generated for the entire population Care Coordination Platform helps optimize revenue under both fee-for-service and VBR payment models Team-based care design helps ensure all team members practice at top of license, reduces physician burn-out, and reduces variation in care Analytics driven Cohort identification high risk, high cost, gaps in care Patient focused care - health concerns, advanced directives, social determinants Extended tools for patient outreach, engagement, and care coordination activities Threshold driven alerts prioritize care coordination Appointment-driven workflows support timely patient engagement Care Team Communications Configurable Care Plan based on heterogeneous data sources Quality Insights at the Point of need: integrated analytics with clinical workflows
Action Items Attendees: Share the presentation with your care team(s) Quality Leaders, Providers, Healthcare Executives Are your care managers and care team working with the same list of cohorts that you are? o Improve on 400+ quality measures with intuitive dashboards. Care managers, and coordinators Does your current population health offering automatically assign plans based on patient s problems and conditions. Document care manager notes and task follow-ups to other members of the care team and push notes bidirectionally back to the EHR for workflow efficiency. Learn More: Stop by the GE Booth this conference, or Contact your Account Manager Email Inside Sales at: EMRInsideSales@ge.com Email presenter: Shirley.j.Garcia@ge.com June 29, 2018 30
Ambulatory Population Health Helping you achieve the outcomes that matter most to you Enhanced Care Quality Personalized actionable Care Plan at the point of care. Help reduce gaps in care with actionable insights from Care Plan dashboard. Help ensure consistent adherence to evidence-based guidelines from recent medical literature. Improved Provider Efficiency Drive early interventions within the patient population through risk stratification Identify both non-clinical and clinical determinants of risk, prioritizing risk groups, and aligning cohorts with best practice care plans Actionable plans of care offer focus for conversation and interventions that matter most for the patient at the point of care. Strengthened Financial Performance Strengthen performance under FFS and VBC models by helping practices ensure delivery of needed services and optimize value of care delivered across the team. Identify and take immediate action on gaps in care. Add-on Chronic Care Management tools offer focus and capture of time spent between face-to-face encounters.