Using population health management tools to improve quality Jessica Diamond, MPA, CPHQ Chief Population Health Officer CHCANYS Statewide Conference and Clinical Forum Sunday, October 18, 2015
Introduction
Our History Our historic experience with HIV care informed our development of an integrated care model The Bronx, New York City 1990 Face of HIV/AIDS had changed in New York City Brightpoint began with residential care
Our Integrated Care Model: A Provider s Nirvana Art Therapy Therapeutic Recreation Health Education Modified Therapeutic Community Individual Counseling Group Sessions Structured Daily Schedule Housing Structure Assignments Shelter Resident Food Acupuncture Medical Care Nursing Care 24/7 All aspects of physical, behavioral and social care coordinated and customized to each patients needs. Social Services Case Management Legal Liaison Family Program PT/OT
Developing an Outpatient Model: Patient-Centered Medical Home Evidence Base For Integrated Care Prevalence of co-occurrence of behavioral health, substance abuse disorder (SUD) and chronic medical conditions Interacting effects between behavioral and physical health Biological, psychological and social factors play a significant role in human functioning and disease Integrated Care Remains Best Means to Attain Our Vision: Improved health outcomes for people, families and communities challenged by health disparities caused by poverty, discrimination and lack of access.
Defining Integrated Care The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms and ineffective patterns of health care utilizations. Source: Agency for Healthcare Research and Quality
Overall Results: Integrated care increases access for hard to reach patients 7,000 6,000 Increasing Access To Services 5,941 5,000 4,738 4,000 3,000 2,000 1,000 1,831 1,407 1,270 2,988 2,235 1,457 3,304 4,246 1,648 1,726 Primary Care Patients Behaviorial Health Patients HIV+ Patients 0 2011 2012 2013 2014 Source: Brightpoint Health Data
Tackling Comorbidities: Integrated care is critical for people living with HIV 70% % of HIV Patients with Comorbidities 60% 50% 40% 30% 20% 10% 0% 2011 2012 2013 2014 HIV and Substance Abuse HIV and Behavioral Health DX HIV and Substance Abuse and Behavioral Health DX Source: Brightpoint Health Data 2014-2015
Result: Internal growth and adjusting to change Since 2012, Brightpoint Health has gone From four locations to sixteen From 300 employees to almost 800 From 90,000 health care visits to over 130,000
Tackling Comorbidities: Why our integrated care model is especially effective Complex conditions require coordination and follow up. Medication interaction. Do you know all of yours? Now imagine you are homeless, hungry and dealing with multiple health challenges. Are you going to look them up? The right hand must know what the left hand is doing Social determinants Shelter as a public health issue Nutrition
Our Patients 2014 Gender Age 39% 61% Men Women 20-29 30-39 40-59 60+ Homless/Unstably Housed Perm. Housing Housing Status 25% 75% 60% 50% 40% 30% 20% 10% 0% Race/Ethniticy White Black Unreported Hispanic
Our Outpatient Model: Homeless FQHC Patient-Centered Medical Home Outreach (Transportation) Care Coordinator (Health Home) Mental Health (Article 31/28) Dental Services Out Patient Drug Treatment (Article 822) Patient Primary Care (Article 28) Nutrition/ Meal Service Medical Case Management Office-Based Opioid Replacement Therapy (Buphenophine) Pain Management
Primary Care Team Med Tech RN Medical Case Manager Patient Medical Provider Behavioral Health Provider Care Manager (Health Home)
Challenges and Barriers: Moving from co-location to integration Start from existing programs and locations. Two models, both have their advantages Bricks and Mortar Integration Services at the same locations Providers can communicate and huddle in person Virtual Integration Services at different physical locations, integrated through HIT Health Information Technology Providers communicate on their own schedules. No need to make time for meetings.
Challenges and Barriers To True Integration Discipline Specific Silos Development of Integrated EHR Work Flows Work Force Development Change is always hard.
Past Decade Represents More Change In Health Care Delivery Than Any Time In History Stimulus Act of 2009 Authorized CMS to offer financial incentives for meaningful use of Electronic Health Records (EHR) Affordable Care Act (ACA) 2010 Most significant overall of the US health system since 1965 Increases the quality and affordability of health insurance Reduces the number of uninsured Americans Lowers health care costs for individuals and government Cutting Costs is Half the Equation, Increasing Quality is Equally Important
Aligning on Quality What Really Matters National Committee for Quality Assurance (NCQA) driving quality improvement Builds consensus by working with policymakers, employers, providers, patients and health plans Promotes accountability for care integration, access, patient satisfaction and reducing health care costs
Health Care Transformation = Workforce Transformation Moving from episodic care to coordinated care supporting population medicine. Asking a new set of questions: Old question: What services do you provide? New questions: How do we reduce costs AND improve population health? How do we best use resources for better outcomes?
It s Not, What s the Matter With You, It s What Matters to You. - Maureen Bisognano, IHI Paramount paradigm shift for providers Focus on reducing/ eliminating inequality and disparities
New Approach Requires New Tools Partnership between providers and payors Non-traditional health care work force Sharing financial risk for the populations served Redesigned IT including integrated data support New care management models Measurement and accountability tools
Example: Provider Dashboard 2015 Q2 PRIMARY CARE PROVIDER DASHBOARD, 4/1/2015-6/31/2015 Measure Types Primary Prevention Secondary Prevention Tertiary Prevention Reporting Entity 2014 NYS Target Goal 2015 Q2 Brightpoint Health Average Provider Panel Size (by PCG) UDS, HEDIS, MU Flu Vaccination UDS, MU Tobacco Assessment UDS, HEDIS, MU,QIP Cervical Cancer Screening UDS, HEDIS, MU, QIP Colorectal Cancer Screening UDS, HEDIS, MU Adult Weight Screening and Follow up DOH Sexual Health Screening Project Gonorrhea Screening DOH Sexual Health Screening Project HIV Screening UDS, MU Tobacco Cessation Intervention UDS, HEDIS, MU Controlled HTN (Last BP < 140/90) UDS UDS, MU HIVQUAL, QIP MU Diabetes HbA1c > 9 % or not tested Diabetes HbA1c <7% VL Suppression (Last VL< 200 copies/mm 3) 42% 90% 62% 36% 53% 95% 95% 69% 68% 25% 45% 76% 100% 31% 97% 32% 14% 92% 72% 73% 87% 70% 26% 51% 65% 100% Meaningful Use 1 196 43.75% 96.89% 52.94% 1.12% 68.60% 16.98% 26.96% 97.48% 56.25% 38% 37.93% 68.42% 85% 2 587 28.22% 94.27% 24.10% 15.23% 91.28% 76.66% 78.66% 97.35% 77.50% 25% 56.96% 61.46% 88% 3 326 19.05% 98.90% 29.85% 4.82% 94.53% 89.42% 82.44% 48.19% 65.38% 23% 53.85% N/A 4 491 32.42% 98.84% 45.60% 10.24% 97.99% 87.70% 77.74% 96.41% 73.15% 25% 49.12% 63.83% N/A 5 644 36.91% 99.42% 37.34% 21.25% 97.89% 58.96% 74.19% 92.77% 62.39% 30% 47.89% 56.52% 85% 6 581 23.65% 95.17% 16.76% 1.77% 89.17% 85.86% 82.35% 92.64% 68.29% 19% 46.55% 63.64% 100% Met or Exceeded Target Goal Approaching Target Goal (within 10% of Target Goal) Has not met Target Goal (>10% from Target Goal)
Example: Provider Progress 100% 90% 80% 70% 60% 50% 40% 2015 Q1 2015 Q2 Target Goal 30% 20% 10% 0% Flu Vaccination Tobacco Assessment Cervical Cancer Screening Colorectal Cancer Screening Adult Weight Screening and Follow up Gonorrhea Screening HIV Screening Tobacco Cessation Intervention Controlled HTN (Last BP < 140/90) Diabetes HbA1cDiabetes HbA1c > 9 % or not <7% tested VL Suppression (Last VL< 200 copies/mm3) Meaningful Use
Individual Provider Dashboard - CPCI
FQHC Comparison - CPCI
Pre Visit Planning Tool - CPCI
Example: Health Center Dashboard
Other Population Health Management Tools identifying the top 5%
% compliant Brightpoint Health UDS Data: 2012-2015 100% 90% 80% 70% 60% 50% 40% 30% Adult Weight Screening and Follow up Tobacco Cessation Intervention Asthma Treatment Plan Controlled HTN Diabetes HbA1c >9% Diabetes HbA1c <7% Colorectal Cancer Screening 20% 10% 0% 2012 2013 2014 2015
Breaking the Barriers: Institute for Healthcare Improvement Collaboration 4.5 Patient Experience: For today's visit, your care team was well organized, efficient, and did not waste your time? Key Brightpoint Collaborative Average Goal 4.4 4.3 4.2 4.1 4 3.9 May June July
Breaking the Barriers: Institute for Healthcare Improvement Collaboration 85 Improvement in Blood Pressure Control Key Brightpoint Collaborative Average Goal 80 75 70 65 60 May June July
Breaking the Barriers: Institute for Healthcare Improvement Collaboration 4.80 Patient Satisfaction: I was able to get all of my health needs met by my health care team. Key Brightpoint Collaborative Average Goal 4.60 4.40 4.20 4.00 3.80 May June July
Breaking the Barriers: Institute for Healthcare Improvement Collaboration 100 Depression Screening Follow Up Key Brightpoint Collaborative Average Goal 80 60 40 20 0 May June July
Successful efficient Systems of Care must: Understand the needs of your patient population Understand the true barriers preventing patients from engaging in care Utilize population health management tools improve quality
Challenge: True integration of behavioral health is particularly challenging Capacity issues Maximum of 30% of visits to primary care centers can be for behavioral care Provider issues Shortage of qualified mental health providers who want to work with our population Expansion of services and populations means finding new providers Pediatric specialists Bi-lingual providers
Complex Challenges Require Multiple Solutions Strategic planning State reform program Managed care and value based payments Health home care management programs Growth through strategic acquisitions and affiliations Hospital system partnerships Fiscal management FQHC Status Grants Making very tough decisions
Key Components of MRT Reforms Fiscal discipline, transparency and accountability Care management Patientcentered medical homes and Health Homes Targeting the social determinants of health $7B Designated for Delivery System Reform Incentive Payment Program (DSRIP) to: Transform the State s Health Care System Bend the Medicaid Cost Curve Assure Access to Quality Care for all Medicaid Members Create a financially sustainable Safety Net infrastructure
DSRIP Transforming the Delivery System From fragmented and overly focused on inpatient care towards integrated and community focused From a re-active, provider-focused system to a pro-active, patientfocused system Allow providers to invest in changing their business models Patient-Centered Transparent Collaborative Accountable Value Driven
Solution: Care Management puts health care reform into action Care management (Health Home) program for multiple comorbidities Chronic health conditions Severe behavioral health challenges Coordinates services: primary care, specialists, social support, housing and benefit applications, etc. Acts as Client s advocate navigating bureaucracy Reduces ED visits, in-patient care and re-hospitalizations
These Solutions Allow Us to Meet Our Overriding Objective: The Triple Aim Better Care Over 85% of our primary care patients are satisfied with their care, provider access and engagement. Almost all would recommend Brightpoint Health to a friend. Better Health Our clinical results meet or exceed national and state benchmarks despite patients representing a less stable population than Medicaid recipients overall. Lower Costs Lower Costs Identify high risk/high cost patients. Provide more intensive care management and intervention toward reducing costly Emergency Department visits and inpatient care.
Result: Internal growth and adjusting to change We maintain our ten Core Values
Result: Internal growth and adjusting to change How? Invested in quality Invested in culture Continuity in executive leadership Brand ownership
Q & A Contact information: jdiamond@brightpointhealth.org (718) 681-8700 ext. 4426