L3: Developing a Portfolio of Projects to Support a Triple Aim Strategy IHI National Forum December 4, 2011 1:00 4:30 Carol Beasley, Institute for Healthcare Improvement Rebecca Ramsay, CareOregon Trissa Torres, Genesys HealthWorks Faculty Disclosures Carol Beasley has nothing to disclose Rebecca Ramsay has nothing to disclose Trissa Torres has nothing to disclose 1
Three Dimensions of Value Population Health Experience of Care Per Capita Cost Words From Don The Triple Aim refers to three goals at once: 1. Better care for individuals as described by all six dimensions of quality in the Institute for Medicine report: safety, effectiveness, patientcenteredness, timeliness, efficiency, and equity; 2. Better health for populations with respect to the upstream causes of so much of our ill health like poor nutrition, physical inactivity, substance abuse and unwise behavioral choices, violence, and economic disparities; and 3. Reducing per capita costs by eliminating waste and needless hassles and, hear me clearly, specifically not by withholding from us or our neighbors any care that helps then specifically not by harming a hair on any patient s head. Donald Berwick, MD; Administrator Centers for Medicare and Medicaid Address at America s Health Insurance Plans Medicare Conference, 9/13/10 2
Session Objectives After this session, participants will be able to: Select a population of focus as the basis for portfolio design Develop a draft portfolio to address a range of Triple Aim design concepts Articulate aims, system measures, and project measures that are aligned across the portfolio Assess investments and capabilities needed to successfully pursue a Triple Aim portfolio Your Aims? 3
Agenda 1:00 Welcome, Introduction and Framing 1:20 Populations and Segments 2:15 Overview of Project Portfolios and Measures 2:45 Break 3:15 Application: Building Your Portfolio 3:55 Investments and capabilities to support a portfolio 4:15 Looking Ahead; Wrap-up 4:30 Adjourn Three Dimensions of Value Population Health Experience of Care Per Capita Cost 4
Design of a Triple Aim Enterprise Define Quality from the perspective of an individual member of a defined population PH The Triple Aim E $ Individuals and families Definition of primary care System-Level Metrics Health care Public health Social services Prevention and Health promotion Integration Social Capital Capability Building Per capita cost reduction Potential Triple Aim Population Outcome Measures (Oct 2011) Dimension Measure Population Health 1. Health Outcomes: Mortality: Years of potential life lost; Life expectancy; Standardized mortality rates Health/Functional Status: single question (e.g. from CDC HRQOL-4) or multi-domain (e.g. SF-12) Healthy Life Expectancy (HLE): combines life expectancy and health status into a single measure, reflecting remaining years of life in good health 2. Disease Burden: Incidence (yearly rate of onset, avg. age of onset) and/or prevalence of major chronic conditions Experience of Care Per Capita Cost 3. Risk Status: Behavioral risk factors include smoking, alcohol, physical activity, and diet. Physiological risk factors include blood pressure, BMI, cholesterol, and blood glucose. (possible measure: a composite Health Risk Appraisal (HRA) score) 1. Standard questions from patient surveys, for example: Global questions from US CAHPS or How s Your Health surveys Experience questions from NHS World Class Commissioning or CareQuality Commission Likelihood to recommend 2. Set of measures based on key dimensions (e.g., US IOM Quality Chasm aims: Safe, Effective, Timely, Efficient, Equitable and Patient-centered) 1. Total cost per member of the population per month 2. Hospital and ED utilization rate and/or cost 5
Global Triple Aim Participants POPULATIONS AND SEGMENTS 6
CareOregon Population All the members that have enrolled in our health plan. Medicaid eligible; low income 155,000 individuals o 66% healthy women and children o 44% adults, many are aged, blind, and disabled o 48% identify as persons of color o 34% speak English as a second language Living across the state but 85% within the Portland Metro region CareOregon s System-Level (broad) Triple Aim Measures HEALTH MEASURES Global Health Status (SF-1) AvgTotal HRA score (health risk status) AvgEQ5D score (functional health status) EXPERIENCE MEASURES Global Rating of Health Care (0-10) % consistently receives pt centered care Avg % meeting HEDIS effectiveness of care index target COST MEASURES Total Per Member Per Month Cost ED PMPM/Utilization Rates Hospital PMPM/Utilization Rates 7
Genesys Example: Our Community A profile of our Community Genesee County, Michigan: Population of 435,000 75% Caucasian, 23% African American, 2% Hispanic/Latino Flint, Michigan (County seat & largest city): Population: 110,000 53% African American, 41% Caucasian, 3% Hispanic/Latino Once a booming General Motors (GM) town 1980s: Over 80,000 GM employees worked in Genesee County Today: Less than 8,500 GM employees remainworking in Genesee County GM Retirees -Flint and Genesee County are still home to one of the largest concentrations of GM retirees in the world Chronic high unemployment rate Genesee County: 11.8% unemployment rate(march 2011) Healthcare Delivery Three competing health systems, including Genesys Health System, an integrated health system that includes the full continuum of care and primary care PHO Genesys Example: Population Level Measures of Health and Care County Health Rankings for Genesee County, Michigan Out of 82 counties in Michigan, Genesee County ranks: 77 th for Health Outcomes(mortality, morbidity) 82 nd for Health Behaviors 74 th for Social & Economic Factors 28 th for Clinical Care(access to care) 8
Genesys Example: Population Level Measures of Cost Dartmouth Atlas, HRR High cost/high utilization region High end of life costs Some evidence of moderation of cost trends UAW Trust Data High cost/high utilization region Pockets of relative improvement *No current ability to aggregate costs across all payers and uninsured Exercise: Populations and System Measures Individually, think about: How you would describe your overall population Possible system measures that would reflect the three elements of the Triple Aim Note these at the top of your worksheet Share your ideas with the people at your table Brief report-out 9
Example Population Segments Everyone employed by your system (or some other employer) Everyone in a particular health plan The population served by a medical home A capitated population, HMO, or potential ACO population Broadly defined sub-populations, e.g. Elderly, working adults, individuals with medical and social complexity, children Everyone in a particular geography (zip code, county, state, HRR, etc.) 10
CareOregon Population Segments Members who have experienced 3+ hospitalizations and/or 10+ ED visits in the past 12 months Members who are also receiving regular mental health services from a community mental health agency Members who receive primary care from one of five safety-net clinics engaged in the implementation of PCPCH Members who meet a complexity threshold as defined by their predicted risk of future medical cost CareOregon Population Segments: Shared Community Accountability Various Social Services Agencies (housing, CD tx centers, disability case managers) Members who have experienced 3+ hospitalizations and/or 10+ ED visits in the past 12 months Members who are also receiving regular mental health services from a community mental health agency Community Mental Health Agency Combinations of all of the above Members who meet a complexity threshold as defined by their predicted risk of future medical cost Members who receive primary care from one of five safety-net clinics engaged in the implementation of PCPCH Primary Care Practices 11
GENESYS EXAMPLE: POPULATIONS SEGMENTS Genesee County Population: 435,000 Genesee Health Plan 25,000 patients Genesys Primary Care Residency Clinics 13,200 patients Genesys PHO Patient Centered Medical Homes 140,000 patients Genesys ACO 18,500 patients Exercise: Population Segments How would you describe your overall population? How might you segment your population, and why? With whom do you share accountability for your population? Report-out and discussion 12
CREATING A PORTFOLIO Portfolio: Definitions A hinged cover or flexible case for carrying a collection of loose papers The diversified collection of securities held by an investor designed to spread risk For our purposes: The set of projects, investments, and capacities that together are sufficient to achieve the Triple Aim 13
Where Are the Edges of Your System? PCMH Specialty Other Employers Schools Health Plans Social Services Public Health Community organizations; faith communities What is Already in Your Portfolio? For your chosen population, what are you doing now? Are there project goals that align with your Triple Aim goals? Discuss at your tables for 5 minutes and make some notes. 14
Building a TA Portfolio Projects Improved Population Health Achieving the Triple Aim for a Defined Population Enhanced Experience of Care Reduced Per Capita Cost Building a TA Portfolio Projects Project Measures Improved Population Health Achieving the Triple Aim for a Defined Population Enhanced Experience of Care System Measures Reduced Per Capita Cost 15
An Integrated Measurement System for the Triple Aim Aim Projects System (population) Metrics Metric A Metric B Metric C Project Metrics Metric a Metric b Metric c 31 Building a TA Portfolio CareOregon Example 16
Building a TA Portfolio CareOregon Example System Measures: Total Cost Inpatient Rates/Cost ED Rates/ Cost Community Outreach Teams: Project Objective Context: Medicaid rate compression Most money spent is for hospital and ED utilization; nationally recognized much of this is avoidable, unnecessary, and often harmful; avg hospitalization= $4-10K Project Objective: Reduce by at least 50% avoidable hospital and ED admissions for CO members in particular target populations 17
STARTING POINT POPULATION SEGMENT Identify HOT SPOT groups 1 hospitalization and/or 6+ ED visits 2 Hospitalizations and/or 10+ ED visits 3+ hospitalizations Stratify each group according to clinical, behavioral, psycho-social characteristics AND clinic location to develop & target : HOT SPOT interventions Medicaid members, enrolled as of March, 2011 683 mbrs (population segment) 1.4% of OHP adults 32% of adult Inptstays 18
Adult Medicaid mbrs (ages 19 yrs +) Average 12 mos TOTAL cost, ED and Hosp utilization by group Data from PCPs 19
Getting Started 10-20 Case Review 1. Identified 10-20 patients that met our criteria (PCPs chose final learning cohort) 2. Reviewed all data we have about these patients (utilization, pharmacy, clinical, mental health, etc), 3. Held an MDT with all involved providers to share collective knowledge 4. Currently attempting to engage each patient via trust-building home visit/assessment after a warm hand-off 5. Come together as a MDT to discuss what was learned 6. Build next steps based on what we learn What will change the course of utilization for these patients? We have some hypotheses: 1. A trusted partner to help sort through the complexity, facilitate problem solving, provide patient-directed education and care coordination Current examples: grocery shopping for low-sodium diet, Wellness Recovery Action Planning, medication selfmanagement coaching 2. Bringing primary care to the patient rather than asking the patient to come to primary care Staffing Plan per team assigned to a geographic region: Community Outreach Worker Community Health RN (shared among teams) NP, Psychiatrist, Addictions, and Community Mental Health support as needed per patient 40 20
Project Measure: Ambulatory Care Sensitive Hospitalization Rate Medicare Dual Eligible Median T1 = 6.37 Median T2 = 5.37 Mann-Whitney test: Time 1 vs. Time 2 p =.002 Unit of measure is admissions per population per month 41 over time System Measure: Overall Hospital Central Tendency statistic = median Utilization Rate PCR = Primary Care Renewal, a Pt-Centered Medical Home Transformation initiative led by CareOregon 21
System Measure: Total Cost PMPM Central Tendency statistic = median PCR = Primary Care Renewal, a Pt-Centered Medical Home Transformation initiative led by CareOregon 22
Genesys Example Key Elements of Population Health Management Strong primary care practice team focused on prevention and chronic care Engaged activated patients Longitudinal care plan coordinated across the system, optimizing care transitions High reliability, quality, experience and safetyassured at all points of care Community engagement to create healthy environments Superior reporting capabilities Aligned payment systems Genesys Example: Portfolio of Projects Initiative Sample Projects Sample Project level Measures Primary Care Patient Engagement PCMH transformation -Health Navigator integration -Community Linkages Health NavigatorSelf-Management Support in multiple sites Care Transitions Pre-Post hospital support Longitudinal Care Plans Clinical Integration Pathways Safety Community Engagement IT transformation Aligned Payment Systems High reliability training Safety event tracking and reporting Daily Leadership Huddles Safe Routes Healthy Schools Advanced Care Planning IT and process transformations EMR, Registry, RHIE Pioneer ACO Bundled Payment Opportunities PCMH Incentives Partnerships with commercial payers PCMH designation and achievementof performance related metrics (cost, quality, access, satisfaction) Patient engagement Patient change in health behavior patterns Patient change in utilization patterns Target group readmission rates Patient Engagement Compliance with protocols Performance against quality and safety targets Staff engagement and satisfaction Provider Accountability Use rates, activity rates Availability and consumption of healthy foods Use of Adv care Plans, deaths in hospital Ability to report on identified metrics Data driven improvement Balanced governance Performance against targets Sustainability 23
Agenda 1:00 Welcome, Introduction and Framing 1:20 Populations and Segments 2:15 Overview of Project Portfolios and Measures 2:45 Break 3:15 Application: Building Your Portfolio 3:55 Investments and capabilities to support a portfolio 4:15 Looking Ahead; Wrap-up 4:30 Adjourn 24
APPLICATION: BUILDING YOUR PORTFOLIO Attributes of an Effective Portfolio of Projects and Investments Risk matches the goals Diversified Periodically rebalanced with new insights 25
Exercise: Building a Portfolio Use blank worksheet and begin to populate in broad initiative areas The 5 green boxes are a reasonable place to start Make note of initiatives, projects and project measures Faculty will circulate and help Report out learning INVESTMENTS AND CAPABILITIES 26
Exercise: Investments and Capabilities Review your portfolio of projects and consider: What investments will be required to succeed? What capabilities will need to be built or enhanced? Portfolio of Projects and Investments Initiative Typical projects Typical investments Capability building -Regional intelligence -Primary care -Longitudinal experience of care -Payment and cost control -Community health Data from ambulances, data from EDs Redefinition of primary care Care for the socially complex Improving health and lowering cost for employees Falls with harm in the community Connections with community resources Community based health promotion and care mgt. Health risk appraisals, and health coaching Integration of existing efforts, ACO savings Development of new skills in the workforce Driving cost savings through population health Cooperation, improvement skills, joint investing 27
Investments and Capabilities: CareOregon Example Initiative Projects Investments Capability building Regional intelligence Primary care Longitudinal experience of care Payment and cost control Community-Based Outreach Teams Staff resources (8 outreach workers, 4 RNs, 1 Manager) High-risk patient registry Time for nonreimbursed primary care activities Multidisciplinary care planning Skills development regarding patient engagement Addictions competency Community health Genesys Example: Investments and capabilities Initiative Sample Projects Investments Capabilities Primary Care PCMH transformation Practice Coaching Certification Patient Engagement Care Transitions Safety Community Engagement IT transformation Aligned Payment Systems Health NavigatorSelf-Management Support Pre-Post hospital support Longitudinal Care Plans Clinical Integration Pathways High reliability training Safety event tracking and reporting Daily Leadership Huddles Safe Routes Healthy Schools Advanced Care Planning IT and process transformations EMR, Registry, RHIE Pioneer ACO Bundled Payment Opportunities PCMH Incentives Partnershipswith commercial payers Development and testing Staffing and training Testing, scale up and spread Leadership commitment Training costs Data systems Time Partnerships Staff and tools Leadership commitment Relationship building Development and testing Scale up and spread Practice Coaching Measurement Patient engagement skill set Improvement science Learning System Leadership Measurement Improvement science Community collaboration Population perspective Project management Physician engagement Cutting edge knowledge Risk taking Relationship building Rapid redesign Flexibility 28
LOOKING AHEAD: LEARNING SYSTEMS AND PORTFOLIOS Components of a Learning System for the Triple Aim 1. System level measures 2. Explicit theory or rationale for system changes 3. Segmentation of the population 4. Learn by testing changes sequentially 5. Use informative cases: Act for the individual learn for the population 6. Learning during scale-up and spread 7. Periodic review 29
CareOregon s Triple Aim Learning System METRICS Learning Global Rating of Health Care (0-10) Avg % meeting HEDIS effectiveness of care index target METRICS Global Health Status (SF-1) Avg Total HRA score Avg EQ5D score (HRQOL) METRICS Total PMPM ED PMPM Hospital PMPM Primary PMPM Specialty PMPM 59 Learning Thanks and Announcements Your feedback CEUs/CMEs 30