Built to Last: Our Population Health Model University of Utah Health Julie Day / Annie Mervis March 9, 2018 Phoenix, Arizona 1
Key components of a population health strategy what do you think? Using your cell phone Text To: xyz123 In the message box write one or two words that you consider key to a population health strategy 2
Objectives 1. Articulate the elements of a working population health management infrastructure 2. Understand the elements of a successful integrated behavioral health model 3. Identify useful measures of success within a population health integrated model and how to work with the community to build reporting capability 4. Understand the approach to creating a value-based contract 3
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Population Health A Little Background 5
Population Health Management PHM means the proactive application of strategies and interventions to defined groups of individuals across the continuum of care in an effort to improve the health of the individuals within the group at the lowest necessary cost. Healthcatalyst 6
Aims of Population Health Increased patient engagement Better patient self-efficacy More appropriate utilization of health care resources Decreased ED visits Decreased admissions/readmissions INCREASED QUALITY OF LIFE DECREASED COST OF CARE 7
Our Team s North Star To proactively enhance patient engagement by establishing therapeutic relationships that result in better quality of life and lower health care costs in a cost effective, sustainable manner. 8
Risk Stratifying the Population Is Foundational 9
Diagnoses, ED visits, Hospitalizations Limited mobility, Limited Socialization, Depression Limited number of diagnoses-fairly stable May need tests updated Health Maintenance Healthy Health Maintenance
The CPG Population Health Model 12
Diagnoses, ED visits, Hospitalizations Limited mobility, Limited Socialization, Depression 13
RISK ADJUSTING THE POPULATION EPIC Foundational Risk Score is currently used for adults Pediatric Risk score was developed internally ADULT RISK SCORE Age # of Hospital Admissions # of ED Visits Chronic Conditions COPD Diabetes CHF Liver Disease Mental Health: Depression No PCP Medicaid Coverage PEDIATRIC RISK SCORE # of Hospital Admissions # of ED Visits # of outpatient visits Breathing problems Mental Health: Anxiety Depression Outpatient medications Medicaid Coverage 14
What are the Building Blocks? A like-minded multidisciplinary team Care Managers Social Workers Clinical Pharmacists Carved out paid time for Care Conferences with the Provider and team 15
Population Health Strategies INTRADISCIPLINARY CARE CONFERENCES Attendees: Provider, MA/RN, Care Manager, Social Worker, Clinical Pharmacist. Frequency: Care Conferences are held monthly for each provider. Patient identification: Referral from provider Considered high risk on risk registry or based on external utilization data from payers. 16
Referring to the Population Health Team 1. Warm Hand-off Introduce the patient to the team member(s) while patient is in clinic. This results in a higher probability that the patient will engage with our services. Often, we can resolve an issue at that time. 2. Consult in EPIC to appropriate service(s) Our referral team will outreach to the patient and set up a future appointment with us. 3. Talk to team member to request Care Conference Discussion 17
Team Functions - PROVIDER Establish trusting relationship with patients Facilitate patient engagement with team members (Refer to appropriate team members) Attend team conferences and contribute to the development of patient care plan Analyze and collaborate on needs of high risk patients 18
Provider Measures Referrals to Care Management Social Work/GATE Clinical Pharmacy Quality outcomes Patient Experience Easy to understand explanations Listened to Answered Questions Understands what is important to you Respects what you have to say 19
Team Functions Care Manager Coordination of care and resources for patient s medical and overall health needs. Home Health/Skilled Nursing Facility/LTAC placements. Coordination of insurance benefits (i.e., Medicare, Medicaid, PCN, commercial). Longitudinal outreach and monitoring of patient s progress toward care plan goals. Coordination of community resources. Assessment of barrier impacting patients health and/or ability to access health resources effectively. Coordination of Care Team Conferences Management of High Risk Adult and Pediatric Registries. Living Well Program Home Visits 20
Care Management Measures Percent of high risk patients with a care plan Goals Treatment Goal Lifestyle Goal Contingency Plan (what to do if something goes wrong) Volume of Touches Calls In-person MyChart Volume per Panel Volume per provider Time Tracker 21
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Team Functions Social Worker Short term, problem-based psychotherapy (3-5 sessions) Depression/Anxiety Screening Gate Consults Health Behavior Assessment Interventions Coordination of resources for behavioral health needs. Behavioral Health Crisis Intervention (suicidal ideation) APS/DCFS cases and referrals Housing 23
Social Work Report for Calendar Year 2017 24
Team Functions Clinical Pharmacist Comprehensive Medication Management (Clinical Practice Agreement) Diabetes Hypertension Hyperlipidemia Asthma Polypharmacy/Medication reconciliation Medication Education to improve understanding of medication regime. Increase medication compliance Adverse Events Monitoring Tobacco Cessation 25
Clinical Pharmacy Measures Number of medication reconciliations done Trend AEs Percent of key chronic medications that are being refilled MTM programs established with number of enrollees: Diabetes, Hyperlipidemia, Hypertension, Asthma 26
Clinical Pharmacy Metrics 27
Team Functions-Nurse Prevention Education Chronic Disease Education Medical record requests from outside facilities DME Screenings Training and workflow development 28
Nurse Measures Volumes for: Individual Education Sessions Group Education Sessions Trainings accomplished Screenings accomplished 29
SHARED OUTCOMES 30
Epic Healthy Planet Primary Care Adult Risk Measures 31
Team effect to improve A1C < 9 on a cohort seen by clinical pharmacy July 2015 June 2016 32
What happens at a Care Conference? What issues are facing Jabba the Hut? Poor Diet? Substance Abuse? Mobility? Depression? Social Support? Financial Issues? Identify the issues and together figure out a plan and goals to discuss with the patient. 33
The Longitudinal Plan of Care This is the Place for Sharing! 34
How do we manage transitions? 35
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How do we support reliable care? Managing Gaps in Care Registry Outreach Care Navigation Center Bulk Outreach Birthday letters MyChart Center-based teams Point of Service Management Pre-visit Planning 38
How do we engage teams in quality improvement? Monthly Team Process Improvement Meetings Review current measure performance and workflow Identify and prioritize barriers Develop interventions Decide on process measures to collect on the floor to monitor implementation of intervention Review impact on quality measure Providers paid average RVU for team meeting time 39
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FY18 Depression screening project 41
CMS Quality Payment Program Preliminary 2017 42
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One Riddle Being Solved 44
Missing Data Community Clinic patients utilization in facilities outside our system Collaboration with our Statewide Clinical Health Information Exchange 45
chie Data Uses Daily ADT reports pushed from chie to care managers Hospital admits Hospital discharges ED discharges Used for outreach and to schedule follow-up with PCP Next LACE score to risk stratify patients The big picture dashboard Hospital Admissions per 1000 ED visits per 1000 Patients with > 4 ED Visits Avoidable ED Visits Next 30 day Readmissions Rate Total Cost of Care 46
DRAFT 47
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Lessons Learned Community-based Dashboard development is an iterative process Language barriers: Technical vs. Operational Face to Face matters 49
This program has been going from strength to strength and I would be loath to see it compromised in any way, as it is a foundational success upon which we should build. - Dr. David A. 50
Pause for Audience Participation Using your cell phone Text To: xyz123 In the message box write one or two words that depict components of the Population Health Management strategy just described. 51
Deeper Dive Into Behavioral Health Integration 52
The Problems That Need To Be Solved PCP varying confidence in addressing behavioral health concerns Encountering behavioral health concerns lead to: Provider burnout Interference of clinic workflow 1 in 4 adults suffer from a diagnosable mental disorder (Brian & Behavior Research Foundation, BBR, n.d.)
January 2014 February 2015 120,000 of 291,350 visits in the University Community Clinics had a co-morbid mental health condition 41% No Co morbidity 59% Co-morbid 54
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Goals of Integration Increase availability of behavioral health services within the medical model PCP support in addressing their patients behavioral health needs Improve patient clinical outcomes and satisfaction through integrated care 56
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Identified Challenges Limited resources for medication management Limited resources for mental health providers due to contractual carve outs and burdensome administrative processes Limited access to mental health providers Challenges navigating the mental health system Limited community resources Social systems breakdown 58
One Lesson Learned Co-location and a standard model practice led to Continued limited access Little communication at team level Fundamentally separate practices 59
Made the Move to Full Integration Partnership with Community Clinics, Community Physicians Group, UNI, Department of Psychiatry, and College of Social Work Chose to focus on comprehensive care of patients, remove any barriers for any patient Embedded Social Workers into hallways shared with primary care providers 60
No behavioral health needs Behavioral health needs discovered Social worker + patient Real-Time Care Team Coordination Triage Assessment Short-Term Therapy Sessions (3-5 sessions) Groups Community Resources/ Referral to specialized services Coordinate with Population Health Connection to internal psychiatric resources Patient Advocacy Crisis Intervention 61
One Way to Generate Revenue Health Behavior and Assessment Intervention Codes 62
Pause for Audience Participation Using your cell phone Text To: xyz123 In the message box write one or two words that depict components of the integrated behavioral health program just described. 63
Getting On Top of Contracting 64
One Contract Deal 65
The Details on Potential 66
STAR Visits: Addressing 90% of HCCs in 60% of Patients 67
80% Adherence to HEDIS/STAR Measures 68
Other Components of the Contract 69
Lessons Learned Quarterly reporting/evaluation is too frequent Double check language in contract to ensure a win/win Start with partners who will be flexible in working to create a win/win 70
ROE= COA/TPI Healthcatalyst 71
RETURN ON ENGAGEMENT 72
Text a one word idea you can use when you return to your organization. 73
Questions? ROE= COA/TPI 74