Designing Reliable Value-based Systems of Care for Chronic Disease and Prevention Frederick J. Bloom, Jr. MD MMM President, Guthrie Medical Group 1/23/15
Where We Want to Be 1. Affordable coverage for all 2. Payment for value 3. Coordinated care 4. Continuous improvement/innovation 5. National health goals, leadership, accountability The Path to a High Performance US Health System A 2020 Vision and the Policies to Pave the Way, pg. 16-21, The Commonwealth Fund
Triple Aim in Action Better Care Better Health Less Waste Better Provider Experience
International Comparison of Spending on Health, 1980 2007 8000 Average spending on health per capita ($US PPP) 16 Total expenditures on health as percent of GDP 16% 7000 United States Canada $7,290 14 6000 Netherlands Germany 12 Australia 5000 United Kingdom 10 New Zealand 4000 8 8% 3000 2000 1000 0 1980 1984 1988 1992 1996 2000 2004 $2,454 6 4 2 0 United States Germany Canada Netherlands New Zealand Australia United Kingdom 1980 1984 1988 1992 1996 2000 2004 Note: $US PPP = purchasing power parity. Source: Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009). 4
Higher Cost Associated with Lower Quality Baicker K, Chandra A. Health Affairs Web Exclusive, April 7, 2004: W4 184-97. 5
Opinion August 12, 2009 10 Steps to Better Health Care By: Donald Berwick, Elliott Fisher, Atul Gawande and Mark B. McClellan If the rest of America could achieve the performances of regions like these, our health care cost crisis would be over. Their quality scores are well above average. Yet they spend more than $1,500 (16 percent) less per Medicare patient than the national average and have a slower real annual growth rate (3 percent versus 3.5 percent nationwide).
The Challenges Unjustified variation Increased complexity Lack of coordination, fragmentation of care Non-Aligned payment incentives Payment for more units of work Outcomes irrelevant Patient as passive recipient of care
Population Health Management Office Redesign Care Management Partnerships in the Medical Neighborhood Value Based Reimbursement
Adults in the US received 54.9% of recommended care Acute care 53.5% Care for chronic conditions 56.1% Preventive care 54.9% N Engl J Med 2003; 348:2635-45
Time Required for Primary Care of Patients Acute Care Preventive Care Chronic Care 4.6 hours/day 7.4 hours/day 10.6 hours/day 22.6 Hours/day
Patient Centered Medical Home Reimbursement Care Management Quality Access Team Based Care T Physician Whole Person Orientation
Operational Workflow Redesign Improving reliability and safety in health care is about designing consistent operational flows An electronic health record is a tool to help create consistent designs, but is not itself the answer Sustained improvement does not rely on I ll remember to do it the next time, does not rely on vigilance and hard work Operational flows make sure that the care we all know should be provided, happens every time
Lean Value Stream Mapping 1. Automate work that can be done by a computer 2. Delegate work that is done at an office visit to trained non-physician staff when possible 3. Hardwire team roles with reminders and EHR tools to enhance reliability 4. Engage the patient
Data Driven Innovation Delegated Team Responsibilities Scheduling Needed Office Visits Non Office Visit Based Care Provider EHR Reminders Pay for Performance
Diabetes System of Care All or None Bundle measure for Diabetes Clinical process redesign Clinical decision support Health Maintenance and Best Practice Alerts Patient specific strategies using registry report data Care Gaps Patient centered strategies Patient report cards Compensation
All-or-None Bundle Measures Nolan T, Berwick DM. All-or-none measurement raises the bar on performance. JAMA 2006;295:1168-70
CMS Diabetes All-or-None Measure Goal HgbA1c < 8 LDL < 100 BP < 140/90 Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Tobacco Non-Use Aspirin Use Complete Bundle Percentage 60% 60% 80% 80% 100% 0% Even if individual criteria have great results, when calculated as an All or None metric the need to work differently (systems of care) becomes evident
Geisinger Diabetes Bundle Measures Quality Standard HgbA1C measurement Every 6 months HgbA1C patient specific goal LDL measurement <7 or as entered on problem list Yearly LDL patient specific goal <70 or <100 Blood pressure control <140/90 Urine protein testing Influenza immunization Yearly Yearly Pneumococcal immunization Once before 65, Once after 65 Smoking status Patients who receive/achieve ALL of the above standards Non-smoker Diabetes Mellitus Bundle Percentage 18
Diabetes Bundle Score Not all patients should achieve each measure for instance not all patients with diabetes will quit smoking Individual component scores for GHS were very good above the national benchmarks Yet initial Geisinger System score was only 2.4% Easy to recognize that a dramatic restructuring of the care provided to diabetics was needed
Diabetes Process Redesign EPIC Data Previsit Planning Reminder letters CareGaps Outreach Clerical Clinic Nurse Case Manager Advanced Practitioner Specialist Scheduling of Flu/Pneumo, Follow Up Immunizations, Testing, Foot Exam High Intensity Coordination/Education Modules of Care Automated Referrals Nurses Providers Patients/Families Nurse Rooming Tool, Process BPAs Alerts for Complex Decisions MyGeisinger, Patient Report Cards
Nurse Rooming Tool
Nurse Rooming Tool Improvements MyG Enrollments Urine Microalbumin 8000 7000 6000 5000 4000 3000 2000 1000 0 Delegate To Nurses Dec-05 Jan-06 Feb-06 Mar-06 88 86 84 82 80 78 76 74 72 70 68 66 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07
Practice Redesign One technique of successful improvement is to link a process that needs improvement with an already reliable process Linked pneumococcal vaccination with the influenza vaccination campaign in the minds of our patients, nurses and physicians A Care Gap pull strategy using letters, phone calls from our call center and e- mails to MyGeisinger patients 23
Pneumococcal Immunization Age >65 3500 3000 2500 2000 1500 1000 500 0 Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 2007/2008 2006/2007 2005/2006 2004/2005 2003/2004 2002/2003 24
Pneumococcal Immunization Age >65 25
Pneumococcal Immunization Age >65 High Risk Patients 26
27 27
Diabetes Mellitus (DM) Health Maintenance Alerts
Patient Activation: Portal Report Card
Diabetes Best Practice Alerts
Diabetes: Patient Letter/Report Card Last 2-3 values displayed LDL values and goals Last BP readings 31
Timely Feedback of Data EPIC EHR allows collection of clinical data without manual chart reviews Data is collected on an individual physician basis, but summarized into site reports to encourage team based solutions and accountability 9 components the Diabetic Bundle being collected this year Bundle percentage is the percentage of the site patients who are achieving all 9 of their diabetic goals
Improving Diabetes Care for 27,258 Patients 3/06 3/07 12/13 Diabetes Bundle Percentage 2.4% 7.2% 14.0% % Influenza Vaccination 57% 73% 69% % Pneumococcal Vaccination 59% 83% 79% % Microalbumin Result 58% 87% 80% % HgbA1c at Goal 33% 37% 47% % LDL at Goal 50% 52% 60% % BP < 140/80 39% 44% 66% % Documented Non-Smokers 74% 84% 85%
3 Year Results in 25,000 DM Patients 305 MI s Prevented NNT to prevent 1 MI 82 patients 140 Strokes Prevented NNT to prevent 1 Stroke 170 patients 166 Cases of Retinopathy Prevented NNT to prevent 1 Retinopathy 152 patients Bloom FJ, et.al. Primary Care Diabetes Bundle Management: 3-year outcomes for Microvascular and Macrovascular Events. Am J Manag Care. 2014;20(6).:e175-182.
Office Redesign It is not the tool created in the electronic medical record, but its implementation into a system of care that creates success Team based workflows involve the entire health care team with clearly defined roles and accountabilities Clinical Information from the EHR is never perfect but improves over time and is actionable Compensation focuses attention, but is not sufficient to sustain change
Population Health Management Office Redesign Care Management Partnerships in the Medical Neighborhood Value Based Reimbursement
Case Management Automated Prevention for all Patients Non Office Based Enhanced Systems for Chronic Disease Proactive Monitoring Integrated Case Management for Multi-Morbid High Tech High Tech Office Based Technology Enabled RN Case Manager High Touch High Tech
Embedded Case Manager Not disease focused Focused on those at most risk Needed for about 15% of Medicare Patients 5% of Commercial Patients One Case Manager to 125 patients
Integrated Case Management Components Population Segmentation Health Promotion Disease Management Case Management Pharmacy Management Core Activities Predictive modeling Risk stratification Preventive care & Screenings Self-management education Medication management Care coordination Exacerbation management TOC Tele-monitoring Brand vs. generic
Case Selection Cost of Care High Risk Patients Selected Conditions CHF COPD Clinical Occurrences Hospital, Nursing home admission Frequent ED visits Clinician Referral
Transitions of Care Pt contact within 24-28 hrs post discharge Telephonic outreach Medication reconciliation Ensure safe transition post discharge with appropriate services in place Home Health DME Safe to be in their home? Facilitate post hospital PCP appt within 3-5 days
Chronic Care Management Heart Failure Diuretic Titration Protocol Daily weights Telemonitoring Education Self management Outreach COPD Rescue kit Symptom monitoring Education Self management Medication Outreach
Population Health Management Office Redesign Care Management Partnerships in the Medical Neighborhood Value Based Reimbursement
Value Care Systems Micro-delivery referral systems High volume specialties Ancillary services Radiology, Lab 360 degree care systems Hospital care Home Health SNF s ER coverage Community resources
Home Health Identify those agencies preferred by practice What services are provided? Therapies such as PT, OT, Speech Respiratory, IV s, Hospice Disease management How do those agencies communicate with the practice? Access & service practices Friday afternoon? 4 5
Opportunities for Innovation Exist in the Nursing Home Current state of care in nursing homes Skilled: 1 in 3 patients are readmitted back to acute care LTC: Average 2-4 hospital admissions annually Opportunities exist to improve quality wounds, falls, infection, pain, etc End of life poorly managed SNFist role
Population Health Management Office Redesign Care Management Partnerships in the Medical Neighborhood Value Based Reimbursement
Am J Manag Care. 2010;16(8):607-614 48
PHN Results (Am J Manag Care. 2010;16(8):607-614) 4 9
ProvenHealth Navigator has a Positive Return on Investment 50
Lessons Learned Along the Way It is possible to improve patients health while reducing costs Requires change in primary care delivery model; the change is not easy Needs active, engaged providers Needs active, empowered team Transitions of care create specific gaps and opportunities Critical to have case manager embedded in primary care site Linkage to every system of care needed Payor/provider partnership essential to success
Questions? Bloom_Frederick@Guthrie.org