Population Health Management In The Medical Home

Population Health Management In The Medical Home Karen Handmaker, MPP (Moderator), Population Health Strategies Patrick Dunn, PhD, American Heart Association Sherrie Peterson, The Evangelical Lutheran Good Samaritan Society Richard Purcell, intellisante

Using Technology for Population Health Management in the Medical Home PCPCC Annual Fall Conference 2015 Breakout Session H: Thursday, November 12, 3:30-4:45pm

Moderator and Panelists Moderator Karen Handmaker, MPP, VP, Population Health Strategies, Phytel, an IBM Watson Health Company Panelists Patrick Dunn, Marketing Manager, American Heart Association Sherrie Petersen, Director, LivingWell@Home, The Evangelical Lutheran Good Samaritan Society Richard Purcell, President and Chief Executive Officer, IntelliSanté

Session Objectives Describe how adoption of technology beyond the EMR is essential to achieve and scale the PCMH model Understand the principles and challenges of implementing new technologies in PCMH workflows Share examples of new technologies that enhance PCMH functions and outcomes

Identifying Waste in Healthcare "Health Policy Brief: Reducing Waste in Health Care," Health Affairs, December 13, 2012. http://resources.iom.edu/widgets/vsrt/healthcare-waste.html

Technology Must Be Designed In LEAN & Process Design Processes Efficient Ways of Working, Scale Automation Technology PHM and Engagement EMR Analytics People Knowledge, Skills, Teams, Leadership, Culture Training

Technology Essential to Scale PCMH Intelligent, Accessible, Scalable Technology QI Patient Engagement Enabled Care Teams Line of Sight Data Integrity

Tech-Enabled PCMH Community Care Management Payer Patient Engagement Mobile Automated Outreach Patient Portals Patient Population of the Primary Care Office Clinical Analytics Clinical Decision Support Advanced Care Planning Claims and Cost Risk Stratification Primary Care Office Care of a patient Others who supply/require information and coordination Specialty Care Hospitals Referral Tracking/HIEs Device Radiology, Lab, Rx Distance Monitoring Telehealth/Telemedicine Remote Patient Monitoring

High Impact of Exogenous Factors Exogenous 60% Volume, Variety, Velocity, Veracity 1100 Terabytes Generated per lifetime Genomics 30% Volume 6 Terabytes Generated per lifetime Clinical 10% Variety 0.4 Terabytes Generated per lifetime Source: The relative Contribution of Multiple Determinants to Health Outcomes, Lauren McGovern et al., Health Affairs, 33, no.2 (2014)

Personality Insights Will Grow What is it? Enables deeper understanding of people's personality characteristics, needs, and values to help engage users on their own terms How does it work? Extracts a set of personality and social traits based on the way a person communicates. 2015 International Business Machines Corporation

Mobile Powers Key PCMH Functions: Integration, Coordination and Engagement

Focus of Our Panelists Describe HIT application and PCMH problem/workflow being solved/enhanced Lessons learned as HIT is implemented/adopted Quadruple Aim benefits Reduced cost Better quality Enhanced patient experience Greater provider satisfaction

Patient and Healthcare Innovations

Overview Translate AHA guidelines and statements that impact Heart and Stroke patients into evidence-based CarePlans Provide a directory of proven AHA guidelines and content designed to significantly increase compliance and patient engagement Empower health care providers, patients and caregivers with trusted CarePlan solutions that are scalable in addressing the needs of complex care patient populations

Enabling Accountable Care Post-acute Strategy Post-Acute CarePlans Improve Quality of Care Reduce Readmissions Lower Provider Costs Result in Healthier Lives

2020 GOAL Improve the CV health of all Americans by 20% while reducing deaths from CV diseases and stroke by 20%. 2010 Reduce CHD, stroke, and risk by 25%. 2020 2010 2020

AHA CarePlan Solutions Derived from the evidence based guidelines

Transformational Platform Approach CarePlan Focus Areas: Heart Failure Coronary Artery Disease Cardiac Rehabilitation Atrial Fibrillation Stroke Rehabilitation Hypertension Cardiometabolic Life s Simple 7 Deployed through technology platforms

Science Review Process Science Guidelines and statements Science Advisory Group Care Plan development Science and Medicine Advisors Content review Technology translation Ecosystem

From here to here.

and then to here.

Digital tools and technology Assessments Communications Connecting patients with their health care team members outside of the traditional health care setting Connecting data from the patient, including biometric data, taken in their natural setting, such as the home, to their electronic health record Connecting patients to digital and interactive tools using smart phones and tablets

Health literacy and health outcomes pathway Cultural factors: Occupation, employment, income, social support, language Access and utilization of health care Demographic factors: Race, education, age Health literacy Patient/provider interaction Health outcomes Self-care Paasche-Orlow & Wolf, 2007 Physical factors: vision, hearing, verbal ability, memory, reasoning

Education Plan How are knowledge, health literacy, and self management skills developed? Is the patient empowered to be an active partner? How is self-efficacy promoted? The Learning Zone Health literacy skills development Progress from low level understanding to higher level knowledge Higher Level Complicated Skills Lower Level Basic Skills VISUAL SOCIAL AUDITORY Is the information in the patient s learning zone? The CarePlan empowers patients and caregivers by targeting their Learning Zone to build knowledge, skills and effective condition management

Building a Support Structure Key results: Empowerment Engagement Health literacy Self-management Healthy living Evidence based Components of the scaffold: Developing goals and action plans (based on CarePlans) Accessing education and information for self-management and healthy living Staying accountable by connecting with healthcare professionals, caregivers and other patients Tracking results (uploading biomedical information)

How does the support structure impact health literacy? Reduced anxiety Social & Emotional support Sharing experiences Health literacy skills Instructional platform

What is the development process? Source documents guidelines, statements Selection Core components Target metrics Goals, priorities, and action plans Assessment plan Education plan Communication plan Progression Knowledge, literacy, skills Evaluation What have we learned? Need to be as engaging as possible Need to be more personalized, interactive, social and relevant Greater integration from one condition to another More standardized

Population Health Management in the Medical Home November 12, 2015 Presenter: Sherrie Petersen Director, LivingWell@Home

What is LivingWell@Home? Provides an opportunity for people to stay in the place they chose to call home Who is that? All of us. Young, old and in between. We all want to be at home whether we are recovering from an illness or hospitalization, managing chronic disease or aging in place. Collects and analyzes information Vital signs, sleep patterns, movement, medication adherence, and activity Information provided to formal and informal caregivers Early detection and earlier intervention

Who LivingWell@Home Serves Multiple Chronic Illnesses Diabetes (53%) Cardiovascular Disease (60%) Respiratory Disease (32%) Mental Illness (30%) Frequent users of health care system Variety of ages Multiple languages English, Spanish, Somali, Lao, American Sign Language Caregivers Formal Informal

Technology of LivingWell@Home Telehealth Technology Blood pressure Pulse Weight Oxygen saturation Glucose levels Sensor Technology Sleep quality and quantity Sleep habits Bathroom usage Movement trends Door opening and closing

LivingWell Center Remote patient monitoring services Registered nurses and non-clinicians Inbound and outbound calling capabilities 7 days a week, including holidays 8:00 a.m. 4:30 p.m. (CST) Based in Sioux Falls, SD Expanding services: Wellness coaching Advance care directive Integrated video

The difference is in utilization According to the National State of Industry Report from Fazzi Associates (2014): Of agencies reporting that they have a telehealth program, less than 25% of their units are in use on any given day.

Average daily utilization of LivingWell@Home service and telehealth equipment 93%

Recognition of: Sleep irregularities Activity pattern changes Bathroom visits Vital sign changes Weight Blood pressure Oxygen saturation Heart rate Blood sugar Cognition changes Can lead to early intervention and detection of: Congestive heart failure (CHF) Chronic obstructive pulmonary disease (COPD) Pneumonia Dementia Diabetes Depression Medication adherence Medication reactions

LivingWell@Home Primary Care Physician Model

Service Benefits Data to support baseline assessments Wellness coaching with goal setting Proactive identification of health and safety concerns Reduce readmissions and emergency department visits Patient engagement enhancement Dual eligible beneficiary community costs lessened Increased patient satisfaction Improved health and wellbeing of population Informal caregiver s peace of mind

Outcomes and Impact Reviewed 31 patients December 2014 through August 2015 Reduced hospitalizations by 70.1% Partner identified 30 instances in which 6.3 LivingWell@Home prevented an adverse 0 event from occurring. 25 18.8 12.5 20.1 Expected Hospitalizations Saved more than $530,000 in healthcare charges 70.1% Reduced Hospitalizations 6 Observed Hospitalizations Resources: Expected data is calculated utilizing Department of Health and Human Services (2012) data of a matching cohort. National Inpatient Survey Healthcare Cost and Utilization Project (2012). Centers for Disease Control and Prevention (2012).

Stabilizing Vital Signs Patient: 75 years old Diagnosis: diabetes, congestive heart failure Time period: June 1, 2015 through September 9, 2015 Systolic

There are 525,960 minutes in a year, the average person only spends 120 of those minutes with their provider. Centers for Disease Control and Prevention

Population Health Management Technologies: Challenges to Implementation & Future Promise

The Revolution in Healthcare: The Affordable Care Act is Here to Stay Private Practice Integrated Health Systems Fee-for Service Outcomes Based Payments Paper Records Electronic Medical Records Care Silos Collaborative Medicine General Treatment Guidelines Precision Medicine Chronic Treatment Disease Management Face-to-Face mhealth

Evolution of Health: Mindfulness Health Wellness Personal Wellness Fitness, Natural Products, Supplements, Yoga Educated/Empowered Patient-Consumer Questioning their therapy Public Efforts to Reduce Risky Behaviors Smoking, Drunk Driving, Obesity Rising Acceptance of Mental Health Limited access to care Mobile Communications Device connection and the Internet of Things Health Insurance for All Population Management Personal Responsibility Intrinsic motivation

Goal: Use Health Information Technology to Fix the US Health Adherence Problem PATIENT NON-ADHERENCE AND DELAYED TREATMENT COSTS $144.9 BILLION ANNUALLY

Collaboration is the Key to Better Healthcare Promote the Mission of the Patient-Centered Primary Care Medical Home Model To Help Guide Patients on Their Journey to Health Collaborative Care Builds Intrinsic Motivation in Patients

HIPAA-Compliant Communication & Data Systems for Population Health Management Outside the Healthcare System Cloud-based Connectivity Progress Tracking Patient Population Population Health Monitoring Central Care Coordinator

Connect Providers - Connect Patients Collaborate For Better Health Outcomes Cloud-Based, HIPAA-Compliant Care Collaboration System Seamless, On-Demand Data Exchange & Communications Network Patient Engagement = Patient Retention Care Coordination Care Transition Care Collaboration Messaging & Communications Document Management Data Sharing Compliance

Chronic Care Management: Incremental Revenue for the Primary Care Practitioner Example: CPT 99490 For Medicare CCM services ~$42 per Medicare Beneficiary per Month Provide 20+ Minutes of Non-face-to-face Care Management Services per Month Use a certified EHR for specified purposes Maintain an electronic care plan Ensure beneficiary access to care Facilitate transitions of care Coordinate care

PCMH Bonus Payments: Financial Incentive for Practice Transformation Primary Care per patient Example 2: NCQA Annual Performance Bonus Examples Cardiac Care per patient Diabetes Care per patient # Patients Annual Performance Bonus $50 $200 $175 100 $42,500 Provide technology solutions to drive standards compliance. Roadmap to Help Network Providers Achieve PCMH Certification Certification Ahead

6 Barriers to Population Health IT Integration Why has it been so difficult to bring technology to healthcare? HIPAA Compliance Standards and Requirements Limit Data Exchange Reimbursement Few CPT Codes, Uncertain Shared Savings Models Limited Opportunity for Tech Innovation Significant Investment in Current Technologies, Limited Staffing & Funding Technology proficiency Physicians and office staff, patients (especially seniors) Data Overload Data without reference is meaningless; Meaningful reports needed Transformation In-office to out-of-office care; workflow redesign; financial models?

Practice-Level Barriers to CCM Implementation: Time, Cost, Risk Significant Costs Without Financial Certainty Education & Training New Staff Position Upfront Costs for Staff & IT Time to Revenue/Profitability 20% Co-Pay for Patients Patient Incentives?

Barriers to Technology Innovation for PCMH Certification Ahead Tech Company/Provider Partnership PCMH Technology Certification Costs EMR Connection & Interoperability Patient Engagement

The Patient is the Only Point of Intersection for All Healthcare Data - RP Bring the Patient Into the HIT Ecosystem: Activation, Engagement, and Collaboration

HIT Will Optimize Care and Improve Patient Health Patient Engagement: Smartphones, medical Apps, wireless devices, and HIPAA compliant data systems offer patients the tools to engage in health practices that promote adherence to medication schedules, selfmonitoring, and care planning Connection: HIT can provide care coordinators and patients with the tools they need to engage in health when they leave the doctor s office or hospital Collaboration: For providers & health systems, HIT can drive new care coordination workflows and data sharing models using cloud-based, HIPAA-compliant data exchange and communications channels that integrate, analyze, and report clinically relevant information Reimbursement: Payors and providers can use Patient Health not just medical records to define new reimbursement models based on patient outcomes and satisfaction with care, patient engagement in health and provider performance But it Will Take Dedication, Time and Money!

Interoperability via the Patient Cloud-Based Patient-Centric Data Collection, Storage & Reporting Collaborative Care Patient Centric Collaborative Care with HIPAA Compliant Data Exchange & Communication

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